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Nurse charting inaccurate vital signs...please help

Posted

Specializes in Education, Administration, Magnet. Has 16 years experience.

I have a problem and I need your opinion on this. In the hospital I work PRN as a Nurse Tech, the aides (or techs) are charting vital signs and I&Os. I have worked a few times with one nurse who refuses for me to chart the signs, she says she wants to do it on her own. That's fine with me, she has a right to do that. But at the end of my shift I check all the charts to make sure that everything is charted, and on her charts I notice the numbers do not match the ones that I provided to her. Some examples are, she changes respirations from 20 to 16, or the temp. from 96.2 to 96.9, O2 SAT from 91 to 95 or if a patient ate 40% of the meal, she charts 100%. I pick up the trays and I know they did not eat 100%.

My problem here is, should I report that? I mean the changes are not life threatening, she just makes the vital signs look better. I know, if I report her, I could not work on that unit again. She would know who reported her. And she is not one of those nice people, you could confront and ask why, she would just go off on me for questioning her. She told everybody in the breakroom that she hates all f****** aides. The are so lazy, she has to do everything on her own. I did not say anything, but all nurses just looked at me at that point.

I really need your help with this one before I call my supervisor.

UM Review RN, ASN, RN

Specializes in Utilization Management.

I know that if I don't like what I see as far as vitals on any patient, I'll go in and sometimes recheck--and I'll get different answers.

One tech in particular seemed to generate BPs that were up to 30 points higher than what I'd get, 15 minutes later! I know she was doing them correctly, I just think she had the type of personality that hyped patients up, instead of soothing them down, if you know what I mean.

Other times, if I notice that someone may not have finished a meal, I'll try to give them something more as I make my rounds.

What puzzles me is why she would not want you to chart your stuff, and then write a "recheck" set of vitals at the time that she repeated them?

Furthermore, you do not need her "permission" to chart the vitals if it's in your job description to do so. Just do them and immediately chart them. If she has a problem with that, let her say so.

If you have any questions, there's also no reason why you couldn't ask your NM for guidance.

NurseLatteDNP, MSN, DNP, RN

Specializes in Education, Administration, Magnet. Has 16 years experience.

You are right, I don't have a proof that she did not retake the vital signs, I never seen her do it, but that does not mean she didn't. I don't see a purpose in changing them like that. But the charting of the meals, I know she did not give them anything exta to eat. I made sure and asked those patients (all 5). So do you think I shall just not report it since I don't have the evidence? And I did not chart, because she keeps her charts at her desk, and tells me not to touch them, just to give her the copy of the vitals.

Maybe you should keep watching, document what you see, before reporting it. Also, document your own work and cover your ass, just in case she lies about you to get you in trouble.

NurseLatteDNP, MSN, DNP, RN

Specializes in Education, Administration, Magnet. Has 16 years experience.

I am saving my vital sign sheets. I figure that would be a good thing to do, if she ever inaccurately charts critical vital signs. So I guess I wont tell. I am just afraid that this has been going on for a long time, and nobody knows about it.

I am saving my vital sign sheets. I figure that would be a good thing to do, if she ever inaccurately charts critical vital signs. So I guess I wont tell. I am just afraid that this has been going on for a long time, and nobody knows about it.

I would think that if she's not charting the meals accurately, she may not be charting the vitals accurately, either.

nursedawn67, LPN

Specializes in Geriatrics, LTC.

I woukd think that if she's not charting the meals accurately, she may not be charting the vitals accurately, either.

I was just thinking this too. Ok I could see the possibility of her rechecking the vs and charting her rechecks, but what about that food acceptance is she going in and feeding them more to "correct" that too (sarcasm). I think the vs to that nurse didn't seem "good enough" so she revamped them to meet her own approval...but this is my own opinion.

I personally think this should be brought to someones attention because what else is she "fixing"?

chadash

Specializes in Nursing assistant.

Does it seem like when she rechecks, the vitals come out closer to normal? Could there be any motivation for her to be less than honest about this kind of thing. I am baffled.

NurseLatteDNP, MSN, DNP, RN

Specializes in Education, Administration, Magnet. Has 16 years experience.

Does it seem like when she rechecks, the vitals come out closer to normal? Could there be any motivation for her to be less than honest about this kind of thing. I am baffled.

Believe me, I am too. I have never seen this before. I mean why would you want to make vital signs look better? It does not serve any purpose

(I think). All the vital signs she writes down are closer to normal. But I have never seen her use a dynamap. But she could say she rechecked it, if she is confronted.

i decided very early on that regardless of the circumstances i would never falsify anything i do regarding my pt care. i was mortified one day when the cna wrote vitals for the entire evening several hours ahead stating that the pt was unruly and difficult to cooperate with. since the pt was stable she opted to just forgo the formality of legitimate vital taking.....:smackingf :nono:

daisey_may

Specializes in med surg.

I know that it is in within your scope of care and job description, but why do you take the patient's vitals for this nurse when you don't chart them and the nurse doesn't use them? And you cannot make assessments and nursing diagnosis as an aide, and the nurse obviously isn't using them, so you're taking the vitals defeats their purpose. So does the nurse do this for EVERY SINGLE ONE OF HER PATIENTS ALL OF THE TIME or just when she pleases?

NurseLatteDNP, MSN, DNP, RN

Specializes in Education, Administration, Magnet. Has 16 years experience.

I know that it is in within your scope of care and job description, but why do you take the patient's vitals for this nurse when you don't chart them and the nurse doesn't use them? And you cannot make assessments and nursing diagnosis as an aide, and the nurse obviously isn't using them, so you're taking the vitals defeats their purpose. So does the nurse do this for EVERY SINGLE ONE OF HER PATIENTS ALL OF THE TIME or just when she pleases?

She does not know that I rechecked the charts. And I think she uses my vital signs as a baseline. She wants me to take the vitals and then give a copy of it. I don't know if she does it every time, because I rarely work with her (:D ). But she does do it while I am there.

RunnerRN, BSN, RN

Specializes in Emergency Room.

i decided very early on that regardless of the circumstances i would never falsify anything i do regarding my pt care. i was mortified one day when the cna wrote vitals for the entire evening several hours ahead stating that the pt was unruly and difficult to cooperate with. since the pt was stable she opted to just forgo the formality of legitimate vital taking.....:smackingf :nono:

oh holy poop. you have to hope that is one cna that doesn't want to go on to nursing school. i don't know what is worse...the fact that she falsified the vitals, or that she told you straight out. i worked with a nurse once who flat out told me she had written down false d/c vitals on a patient of mine i had asked her to sign out. you'd better believe i ran after that pt to get real vs and have never let her touch another pt of mine since.

Does it seem like when she rechecks, the vitals come out closer to normal? Could there be any motivation for her to be less than honest about this kind of thing. I am baffled.

well if she has a care plan and a goal with interventions geared toward say keeping respirations under 20, she may be fudging the numbers a bit to reflect her goals as "met". Same for b/p food intake etc... take a look at the chart and see what the care plans say and specific nursing diagnoses and goals. This may tell you why she is doing what she is doing. Plain wrong! (if this is really happening that is...)

TachyBrady

Specializes in Telemetry. Has 13 years experience.

I was always under the impresson that false documentation is a very serious offense. PCPs use vital signs to guide treatment decisions. A high or even borderline high blood pressure could warrent changes to the pt's medications. Low normal oxygen saturations could indicate the need for a home O2 evaluation. Falsly adjusting these values to normal could prevent needed medical interventions. The same goes for food consumption... a poor PO intake needs to be investigated for the cause and/or need for suplements or dietary adjustments.

I most certainly would report it to the unit manager. My unit manager is very good about keeping these kinds of conversations confidential. If the UM deems this a legitamate concern, he/she can follow up with their own investigation that hopefully will no longer involve you. This way, you have covered your butt while possibly preventing harm to this nurse's patients is she is indeed falsely documenting.

Iworked behind a nurse once, the orders were to contact the md if vs were hi/low per certain criteria...if md orders were to call md if pulse was over 100 she would always show that pulse was 90+ same with cbc i would look over the past readings and they were frequently different than what was on chart

i tried to talk to her and she became defensive and angry . soon after she quit . problem transported to some other facility but i still have feelings that i put unkown pts in jeopardy

JBudd, MSN

Specializes in Trauma, Teaching. Has 40 years experience.

I would go to the nurse manager and ask her to help you out with the situation. Tell her you feel your work is not being respected if the nurse thinks she has to recheck all your vitals, since the numbers you gave her are not the ones on the chart and you are not allowed to chart them yourself. This makes the assumption that she rechecked them all, and not that you are accusing her of false charting. If she is, it will come out eventually without your actually accusing her of it.

One of my former managers was always asking if we had gone to the person first to resolve problems one to one first. Tell her you are not comfortable with doing this because of the comments made in your presence in front of others about the nurse's opinion of "f----- aides".

Remember, whenever making a complaint of another's behaviors, to own your own statements, "I feel my work is not respected", "I am not comfortable with this because ...", etc.

ICURN_NC

Specializes in MICU.

Oh, what JBudd said is a great idea! :yeahthat:

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