Incomplete Documentation- New Grad

Nurses General Nursing

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Incomplete Documentation- New Grad

On my drive home 45 minutes away from the hospital, I realized I forgot to finish my wound documentation. I did the wound change, I took a photo of the wound like the order says and it is in the MAR as proof that I did the wound care. I only charted that the dressing was changed and what was used.

I forgot to document what the wound looked like. I know! What a fail! What in the world was I thinking. I had my first RRT on this shift so in a way I was just feeling disoriented. I know it shouldn't be an excuse. 

Now I'm overthinking about what to do to correct this. I do not work until Saturday again. I know this particular patient will still be in the hospital on Saturday. I know I should text my preceptor letting her know my mistake. I just feel like a huge disappointment. I'm within my last few weeks of orientation & I feel like I should be better than this at this point in orientation. 😞 

You are way too hard on yourself. You did not forget to document what the wound looked like. You took a picture! Feel free to email your preceptor, if you think it will give you some relief. 

I think your new grad anxiety has gotten the better of you.


6,694 Posts

^ Agree.

Sorry for being a little tough love or whatever, but:

I'm so perplexed/annoyed about WHERE this idea comes from that we should be so nursing...even during the learning process. Is it the type of people drawn to nursing (doubtful since there are many "types" that may be drawn to nursing)? Is it the way we are taught in school? Some of that. Wrong ideas passed on to new generations of nurses? Some of that, too. Employers take advantage of this...these thoughts of ours keep us on the rails, always waiting and expecting to get in trouble/be criticized or blamed for why things are the way they are, etc., etc.

I do mean this kindly--please work to change your thoughts on this kind of thing. For your own well-being. You took care of the patient, which is the #1 most important thing, always. I'm guessing just about every single one of us has had a hefty handful of instances of remembering things we intended to do while on the way home or when settling down at home.  If it's important we call back and let someone know. If it isn't, we likely just try to do better next time.

Take a deep breath. No more internal dialogues about what a huge failure this was or you are. Everything's okay!


Specializes in Psychiatry, Community, Nurse Manager, hospice.

JKL33- in short, it's sexism that caused this.  It's systemic and will take generations to weed out of nursing culture.

For the OP:

I am a good nurse.  Here is a short list of the things I forgot as a new nurse and unnecessarily freaked out over:

walked out of the hospital with albuterol inhaler in my pocket. Panicked. Called.  Drove 2 hours to return it even though charge said I could just wait until my next shift. 

Left a patients long acting injectable in my car after I couldn't find him in the community. Went to a wedding the next day and realized it wasn't there for the next nurse to give him. Called in a panic! They used a sample. NBD.

Here is an example of  something I did that I had to forgive myself for:

My hospice patient went to the inpatient unit. She was asking for me. Her sister called me and asked that I go see her. I said yes and I planned to go on Tuesday because I was in the area that day. She died on Monday and never got to see me. I felt very bad about this, and it still bothers me sometimes but I forgive myself. I'm not perfect. 

Something I felt terrible about but later found out was not my fault:

Admitted my home hospice patient to the inpatient unit as she was having exacerbation of symptoms. Inpatient RN asked me to come see her because she was wailing, confused and they needed help with her. Saw my patient, looked at the meds and asked why she wasn't getting scheduled Ativan, as I had put in a verbal for that 2 weeks ago and doc approved it. No Ativan in the orders. I figured that I didn't put it in the system and I felt terrible. Apologized. Told my manager. Turns out I did put it in the system and doc forgot to sign it so it disappeared. 

My point is, that the longer you practice the more real guilt will take the place of the false guilt you feel right now. Learn to forgive yourself now, because it's a necessary thing. One day you will make a mistake that really affects a patient, a family member, someone and you will need to forgive yourself. 





21 Posts

I've been there too. We've all been there where we have forgot to do something. And it usually clicks on our way home or when I'm taking a shower. I use to eat myself up for it. One thing I forgot as a new grad was to document that I did my admission skin check with my preceptor. The good thing about when we make a mistake, is we never make it again. You'll remember for next time to document what the wound looked like. 

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