Yesterday, I had a pt on Q4 vitals, due at noon. I was doing my physical assessment around 12:30 and asked the pt if anyone had been in to do her blood pressure and temp yet this afternoon. (In our facility techs usually do the vitals but nurses are responsible to see that they are done). THe pt said no, so I told her I'd be right back with a b/p cuff to get them. On my way out, I grabbed pts bedside chart where all the flow sheets are. I decided to fill in the flow sheet on my assessment first, so as to be sure that I didn't forget anything (so I could get what I forgot when I went back in to do vitals) I noticed that the vitals were filled in. It was 12:40 at this time. The time given for the vitals was 1300. So I went 'huh' and brought chart to my preceptor.
Preceptor reviewed the chart, noted the times and suggested I go back in and question the pt a bit more. So I did. Pt stated no one had done her vitals since the morning. Pt is alert, oriented and on no meds (post partum) so the question of the pt being confused is small.
So preceptor and I went to the tech responsible and asked her about it. She said yes she did the vitals. We looked at tech's record sheet and checked the vitals she'd written on it against what was charted--they matched except O2 sat was written on chart and not on tech's record sheet. We told her that the time was charted wrong and that we were worried maybe she wrote the wrong pt's assessment in the chart. Tech felt pretty strongly that she wrote said pt's vitals in right chart. It was all very nice, professional. No assumptions, no accusations.
next preceptor and I went to charge nurse and pulled her aside privately and showed her the chart, noted the time, and explained our talk w/ the tech. Charge said tech was experienced, came to us from a diferent floor but she would talk to her.
I returned to my pts room to collect a new set of vitals and document them. Preceptor spoke with the tech, explained that we didn't want to come across as accusatory or whatever but that we were just worried someone else's vitals got charted wrong, and that would mean that someone else wouldn't have vitals charted, but that the nurse responsible would eventually figure it out.
A bit later, the tech came up to me and told me that she is having a hard time with military time, and that she must have done the vitals at noon, but wrote 1300 since she was confused over what time it was.
I told her that we all have trouble learning military time, its understandable etc. We kind of laughed and commisserated about learning military time and left it all at that.
***
Ok, I know you don't make assumptions. But someone who has worked at the hospital for a couple years should know military time. And I know that the vitals were not done at noon because the pt was at a class and didn't get back to her room til a bit after noon. Now maybe the tech used noon in a broad sense...anytime between 12 and 12:30....
I am uneasy about it. I feel that I may have caught someone making up numbers. Maybe not. It just isn't sitting right with me. But charge knows about it, its out of my hands. Right?
Does it sound like we handled it right?
And what would you do now if the tech was assigned to your pts? I try to get the vitals myself but there are only 2 or 3 bp machines on the unit and the techs have them in use to to am and pm vitals, so its not always something I can get to before the techs do. Should I just watch and wait? Or let it go? or what?
KrysyRN, BSN
289 Posts
I would have asked the rest of your Q4 patients if they had their vitals taken.
The tech may have been fudging on a few of them.