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I got called into the office and "written up" for some missing paperwork. The thing is, in my nursing notes, I specificially mentioned that paperwork and what I did with it.

I was in shock about being called in and said "I guess I could have lost it", but the thing is, when I read my note, I said what I did with it.

What would you do?

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

Did you sign the write-up?

Why would you be mentioning paperwork in the nurses notes?

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It was a weird situation where I was doing part and another nurse was doing part. I didnt want her to get confused, so I wrote a note that she could read about which paperwork was done and where it went. I was new and afraid I'd never remember it, so I put it into a note.

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Specializes in Critical Care, Education.

Ugh!

You probably 'stepped' in a P&P violation. All organizations I have worked with (and since I am older than dirt, that is a lot) have rules that govern what is supposed to be in the notes. Referring to specific forms, operational issues, or other non-patient tasks is not approved. So - you can't say things like "incident report completed", "Intervention information transcribed on to Core Measures worksheet", "prescribed med not available, filled out pharmacy request" ... and so on. Of course, you DO need to inform other staff about this stuff, so that's the Catch-22. Maybe you could just stick some post-it notes in your pocket for reminders and such.

So sorry you got caught up in this. Hopefully, it will be a one-off, and you'll never get hit with it again.

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