Published Jul 12, 2009
My manager is busy with little time to touch base with staff, except to pass on administration's directives. The few times I've had her undivided attention (new nurse, going on five months) she brings up a deficiency--something that happened maybe 6 shifts ago. I feel blindsided & unable to defend myself because I can't specifically recall the events of the day. My management skills are improving, my task lists are growing shorter & I'm more proactive/productive. Just wondering, do you all save your pt assignment sheets forever??? I have been throwing them in the shred box after documentation is done, but maybe should save them to cover myself--thoughts?
If you decide to keep your note sheets be sure to keep that info to yourself. You don't want some backstabbing coworker to take that info to the supervisor and find yourself getting fired for HIPAA violations.
I am still in school so I cannot speak from experience as an RN, but from previous work experience at a clinic I would say it is not a good idea to keep your information sheets on the off chance someone finds out and this gets you into bigger trouble. I would on the other hand set up an appointment to speak with your manager to ask how they think you are doing (to make it look like you aren't coming in to simply be confrontational) and let him/her know that it makes you uneasy how you are being treated by them. As managers are very busy sometimes they forget that the people they manage are people too. Just a thought.
OK, it's your notes.... as long as you DO NOT allow the information to be comprimised and it's in your personal residence AND you don't talk about it you are pretty much untouchable. And if for some unknown reason somebody is in your house that you don't trust and sees them in your lockbox..... All you have to say is "I keep them for legal reasons" in case I'm ever called to testify on a case. Do not duplicate them, fax them into your computer etc... They are your "Original notes" from that date, only for your own review and learning experience.
Those are gonna add up though. Better get a big gun safe to stuff them in.... Or, just chart everything like you're a camcorder right?
Or, just chart everything like you're a camcorder right?
Robo-nurse... I wish! I've noticed some nurses have piles of assignment notes in their mailboxes, so maybe others are feeling the same pressure. Not sure if that makes me feel better or worse.
I save all my sheets. Within a month after coming off orientation I got called on the carpet about a pt I had had 3 weeks earlier. I admitted her one night and she died 3-4 days later. Being able to pull my sheet allowed me to fully remember the pt/situation AND was proof to the powers that be what took place before this pt got to my floor (report taken from ED). Most of the details of the case were not even being looked at and that sheet saved my butt. I quickly learned that the only one that has my back is me.
Next time I'm called on the carpet re: any case I plan to tell them I need to jog my memory and will get back to them the next day. It seems unreasonable that someone should be put on the spot and expected to have immediate answers.
OK, you need some more advice on this......
Really you do,
Do not let anyone else know they exist, if they flub and someone spills beans like, to a lawyer, they can subpoena your notes..... just 2c.
A tactic I used recently was simply to say, "The patient was stable on my shift", "The patient became unstable on the next nurses shift and that is his/her responsibility to address".
Managers/Day Rn's always seem to be trying to blame the prior shift for their problems.
Sorry, NO DICE!
I would be nervous about keeping notes past a few shifts. It seems to me that anything worth saving should have been properly documented at the time, including ED report if only given verbally. I want anyone looking at my charting to get a clear picture of the events of the shift; he or she should be able to see that I did a good job taking care of my patient, keeping him or her safe, etc. I see this as not only CYA, but as part of good patient care by ensuring continuity of care. It amazes me how little some nurses document. I know they spent the shift giving excellent care, but to look at the chart, they did nothing but give meds.
solneeshka, BSN, RN
If you take them home, it doesn't matter if you keep them secure or don't remove them from your home, you can get fired for doing that. It's happened to many nurses who have posted on this site. Do you have a locker at your facility? Maybe you can stash them there for a time. But really the best thing is to simply document really thoroughly. Maybe sounds like a pipe dream right now! But as you get more experienced, you will have more time to do this and won't need to continue keeping the sheets.
I usually keep my notes at home in a file for the legal purposes. If you're scared, you can crossed out the person's name and MR number. However, I always write the date on top of my note so I'll know what happened during the shift.
Another thing you can do is to print the receipt from the Pyxis at the end of the shift and keep it with you. So just in case if the manager or someone asked you a question about the med that you pulled out, you can always refer it from the receipt.
I hope this helps.
Since I first posted this, I have been much more thorough in my notes, especially if the patient has eventful occurences-weird vs, test results, etc. Thanks for all your advice--I love being able to come here to talk!
That brings up a concern of mine. I worry about my documentation. Sometimes I get so busy that I have to spend time catching up with it at the end of my shift. That worries me since I know this would be the time to forget something that happened during my shift.
I know the advice is to chart as you go, but it is easy to get sidetracked when I try to do it that way. For instance, I got interrupted 3 times while documenting on one chart the other day.
By using the site, you agree with our Policies. X