Need some advice about charting (RN)

[SJE RN]

My pt calls me into the room and requests a nebulizer treatment. I call Respiratory Therapy and the guy screams at me at the top of his lungs saying he will come when he can. My pt is getting really anxious. Pt complained saying that the Respiratory therapist walked in and out of the room without giving him his treatment. The Respiratory Therapist documented it as pt refused twice at 2200 & 0400. I called respiratory 4 times and no answer. I gave the nebulizer treatment myself and documented...

Pt requested nebulizer treatment. Respiratory therapist ____ ____ notified. Pt complained "I never received my treatment, respiratory therapist fixed my bipap machine and walked out". See MAR. Nebulizer tx was administered by me, RN. Pt vital signs stable, pt currently sitting in bed with wife at beside. Continue to monitor.

Should I have documented as I did? I was told by seasoned nurses to cover myself since the pt will be complaining to administration and I did administer the tx. Was there a better way to handle this?

[rn/writer, RN]

You should talk to your manager who should then take it up with his manager. Let the top dogs duke it out. If a patient tells you they never got the neb tx., you could fill out an incident report, as well. I wouldn't ordinarily do this, but if this guy is a frequent offender, some documentation is in order.

It's not your job to sort out this mess. But you are in a position to gather information that affects you and your patients. You can also talk to your co-workers and see if he gives them guff, too. If this RT has a pattern of neglecting his duties/making mistakes, smart people would be looking at disciplining him before he truly harms someone.

[canesdukegirl, BSN, RN]

You should talk to your manager who should then take it up with his manager. Let the top dogs duke it out. If a patient tells you they never got the neb tx., you could fill out an incident report, as well. I wouldn't ordinarily do this, but if this guy is a frequent offender, some documentation is in order.

It's not your job to sort out this mess. But you are in a position to gather information that affects you and your patients. You can also talk to your co-workers and see if he gives them guff, too. If this RT has a pattern of neglecting his duties/making mistakes, smart people would be looking at disciplining him before he truly harms someone.

Exactly what I was going to write, M!

[Altra, BSN, RN]

Sorry I don't have much input, I'm still a student. I read these forums somewhat regularly, but HAD to sign up to ask about this. Tracking devices? Like GPS thingees that tell when and where the nurse is? Is this normal?

At some hospitals, yes, this is the norm.

[chocolatechip]

At some hospitals, yes, this is the norm.

Thanks for responding. That sounds odd, not to mention a little disrespectful IMO. Another eye-opener.