Lost in the Details

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Specializes in cardiac-telemetry, hospice, ICU.

I was getting report this morning and was listening to the myriad of details about each patient; order changes, labs, vanco troughs due, how they took their meds, troublesome family members, how many times they asked for pain meds, etc. While I stood in one patient's room he simply didn't look right. he seemed to be very tachypneic and I was told, "yeah he does that does that sometimes". He does that sometimes? As soon as the outgoing nurse left the room, I did a quick assessment, his RR was 40! Long story short, my patient after multiple interventions went to the ICU and was intubated and is doing OK. After the crisis, I looked into the EMR and saw all the respiration rates were entered by the night techs as 16, 18, 18. My point is please, as nurses don't overlook the patient right in front of you for the millions of details and paperwork that we all must face.

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When I worked as a tech in a hospital I saw so many techs falsify documentation. I remember when I started out as a sitter (was still a cna and had my own password for documentation) the techs would walk in the room and take vitals. Most of the time I had already documented RR. when I would go in later to document something else, many times I would see a vast difference in the techs number and mine. Not to mention, I was sitting right there when they took vitals. I could SEE that they weren't counting RR. Since then I just can't trust someone else's v/s documentation. This also happened a lot with my first job. To avoid calling the doctor, nurses would falsify BPs, BGs and RR. One night I had a resident whose BG would get extremely high. I took it and it was about 500. Parameters were to call if over 400. I was new and the other nurses told me, just enter 398. "You'll see a lot of 398's in his chart." Um, no thank you. While the doctor was not surprised, he still ordered me to increase the insulin dosage. I'm glad you did something about your patient. I've seen nurses feel bullied into going with whatever the other nurses say.

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I agree. I hate when I see the I's and O's made up. The aides go around at 5am and document these on the sheet inside the room so we can enter them into the computer and so many times I'll see an output written even though I'm absolutely positive the pt had no/less output. They don't understand what an important assessment I and o's are and we can't just make them what we think they should be.

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Great post! I very much agree.

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Specializes in Medical Oncology, Alzheimer/dementia.

I worked with a CNA once who told me that at her other job she "will make up a temp in a New York minute." Ever since then I've been leary of using the vitals of CNAs. For the most part I work with really good CNAs but the pp was right, I'm not sure if they realize how important numbers are to our assessments.

I hate following a nurse who eyeballed the patient early in the shift and never again. This happened to me a lot working nocs in LTC. The med tech would take vitals and give the patient their meds, the nurse would be clueless to any changes.

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Specializes in Family practice, emergency.

Wow. "Yeah, he does that sometimes." Sheesh.

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In my past two years at nursing school I have followed many different nurses. Being a student and new to charting, I would look over every detail with a fine tooth comb. It is my conclusion that the nurse who documents accurately is the exception, not the rule. I'm talking about six different hospitals and probably 10 different floors. I can count on one hand the nurses I have seen actually assess their patient and document correctly.

When I've asked my instructors about it, the only answer they have is something like "Yeah....they shouldn't do that. At least you'll know what not to do."

Does anyone have any tips or advice for what to do when you document behind someone and you know their entries are wrong? Do you bring it up?

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In my opinion as a nurse on a busy telemetry floor, assessments can change drastically from one nurse to another! If you feel the patient was not cared for or put in danger then yes I would say something, otherwise chart your assessment for your findings and take care of your patient as needed!

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In my opinion as a nurse on a busy telemetry floor, assessments can change drastically from one nurse to another! If you feel the patient was not cared for or put in danger then yes I would say something, otherwise chart your assessment for your findings and take care of your patient as needed!

Unless I see with my own eyes that a nurse isn't documenting properly, I wouldn't question anything out loud. As you said, patient's conditions change. As to a student's question as to why false documentation occurs, well, I can't think of 1 nurse who goes into work thinking "I think I'll go into work and be lazy today and not document properly." In many hospitals and nursing homes, there simply isn't time. It doesn't make it OK. It IS scary. But CNAs and nurses are forced into these situations sometimes. If we tell the truth and say there simply isn't enough time, we're accused of poor time management. It couldn't POSSIBLY have anything to do with unrealistic staff to patient ratios.

In the case of the OP however, this wasn't two separate assessments at two different times. 1 nurse brushed it off as it was happening in front of another nurse.

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Specializes in geriatrics.

For these reasons, I make my own rounds on my residents. I don't care if the Aide said they checked or not, because I'm the one in charge. I need to be certain of their condition.

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What great advice! A 20 sec look is worth a mountain of documentation. It is also reassuring to the clients, who believe they are being looked after... and a silent heads-up to the CNAs that they are being held responsible for their work. "Mrs. Smith looked like she was breathing a little fast, and this is a change from what you charted. Please repeat her respers every hour for three hours and let me know what they are."... emphasizes that what they chart is important and attended to better than any other action. It is also non-judgmental - because patients and and do change rapidly at times.

James Smeltzer

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What great advice! A 20 sec look is worth a mountain of documentation. It is also reassuring to the clients, who believe they are being looked after... and a silent heads-up to the CNAs that they are being held responsible for their work. "Mrs. Smith looked like she was breathing a little fast, and this is a change from what you charted. Please repeat her respers every hour for three hours and let me know what they are."... emphasizes that what they chart is important and attended to better than any other action. It is also non-judgmental - because patients and and do change rapidly at times.

James Smeltzer

Very good advice. It addresses the issue in a non judgmental way.

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