nurse doesn't do her charting

Published

I work night shift in a specialty surgical hospital. We get lots of admits, even well into my shift, and patients tend to discharge the next day (not all, but most).

There is one day nurse in particular, who never seems to get her work done. She frequently times out the autologous blood re-infusion drains and has to waste the blood, and she barely does her hourly rounding charting. Most concerning though, is she often doesn't enter her admission assessments, saying that she'll come in and do them tomorrow. I had one patient that she did this on, and I went back in and looked at their chart after discharge, and she hadn't entered one at all, and it was now 48 hours post admission. She even told an orientee to not worry about charting, they could do it later and to make sure meds were passed and such, then went home and left the orientee at work hours after her shift trying to catch up on charting.

I have brought these issues up with both the day shift supervisor/charge nurse and my unit manager, and am frequently told that "day shift is so busy" or that "they have 24 hours to get the admission assessment in". I feel as though my concerns are being pushed aside and swept under the rug, and I worry for both patient safety (what if we have an emergency or have to transfer a patient out and I can't present all the necessary data because she wasn't charting properly), as well as for my own license when I follow her. I am at my wits end, and I have no idea what I should do.

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You have done what you can do. Now you need to decide if this concern is enough to make you seek employment elsewhere. The nurse acts this way because management allows her to do so. They give you the excuses for her and expect you to stop complaining. Perhaps the nurse they hire in your place will have the same work ethic as the other nurse, so the unit will be one big, happy, dysfunctional place to work.

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Specializes in Adult Primary Care.

I agree, you have done all you can. If it bothers you that much, I would probably start looking for another position!!

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Specializes in NICU.

That will be the status quo until a patient sues the hospital and that nurse and the hospital has to explain what happened without documentation. The saying" If it's not documented, it didn't happen" applies.

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I worked with a similar coworker. We all wondered why and how long management was going to put up with her. It did go on for several years but she was finally let go.

I know it's not ideal, but I can't imagine a situation where the patient's care would be delayed or harmed in an emergency or transfer because something wasn't charted. Your license is not endangered by poor charting from the nurse you follow.

That assessments can be completed within 24 hours. This is kind of normal operating procedure. If I get an admit near the end of my shift I will take care of immediate needs, chart a quick assessment, vital signs, check the dressing, give pain meds, etc., and tell the nurse that follows me they will need to complete the admitting assessment paperwork.

If every time I followed this nurse there was little charting done even on an admit she'd had for several hours I'd show my charge nurse. Maybe if enough staff consistently complain, show what is not being charted, management will get tired of it and let her go.

To be fair day and evening shift are extremely busy. (Yes, I know nights can be busy also, I worked nights for 17 years.) I hope I'm not as bad as the nurse in your situation but I will always prioritize patient care over charting, and to be honest my charting tends to be the bare minimum I can get away with.

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Specializes in Emergency, Telemetry, Transplant.

You've reported it. If you just find it annoying that she is not pulling her weight, either you ignore it and worry about you or you look for a new job.

In cases where it actually impact pt care, you could write an incident report--as always, facts only and no names: "Pt has been admitted to the unit for 27 hours. No admission assessment has been charted." Rather than just getting that nurse in trouble, it may (?) serve to open some eyes as to an issue that is preventing nurses from completing the charting on time. If you go this route, it may come out that you are tattling on people, and you also have to be prepared for nothing substantive to come of it.

Also, I might have approached it a little differently, but I think it is appropriate to tell an orientee that pt care takes priority over charting 99% (100%?) of the time.

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Agree with the above. Now that you've reported what you believe is problematic, you can "mind your own back yard."

Your license is not at risk here. If you are in the course of patient care and are interested in a piece of information she should have charted, you use other means of getting the information or else simply proceed to perform as a prudent nurse without that information would perform.

Checking on her work in order to confirm her apparent deficiencies unless that is a role for which you were hired is a road to destruction, probably more so for you than her.

Move on, take good care of patients. Let others worry about her.

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I 100% agree that pt care takes priority, I'm usually that way myself. But when she has two admits and no other patients the entire day, and NOTHING is done, well, that speaks of poor time management. As far as her telling the orientee to "leave charting for later" it makes absolutely no since, because she told her to give meds and chart later, empty drains but chart later, and all that. It is also pertinent to note, that the facility has computer systems in every patient room. Assessments take me about 15 minutes to complete and chart at the bedside. Meds should be charted as they are given.

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Specializes in Medsurg/ICU, Mental Health, Home Health.
Now you need to decide if this concern is enough to make you seek employment elsewhere. The nurse acts this way because management allows her to do so.

This!

Honestly, unless there is some sort of neglect occurring, this is the only way this concerns you.

I understand what it's like to be the person who completes her job but is aware that others consistently underperform but are considered to be equal - it's frustrating and it's not fair; however, because you most likely can't change her spots, so to speak, you can try to find a way out if you feel that you would receive what are you due elsewhere.

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I worked with a similar coworker. We all wondered why and how long management was going to put up with her. It did go on for several years but she was finally let go.

I know it's not ideal, but I can't imagine a situation where the patient's care would be delayed or harmed in an emergency or transfer because something wasn't charted. Your license is not endangered by poor charting from the nurse you follow.

That assessments can be completed within 24 hours. This is kind of normal operating procedure. If I get an admit near the end of my shift I will take care of immediate needs, chart a quick assessment, vital signs, check the dressing, give pain meds, etc., and tell the nurse that follows me they will need to complete the admitting assessment paperwork.

If every time I followed this nurse there was little charting done even on an admit she'd had for several hours I'd show my charge nurse. Maybe if enough staff consistently complain, show what is not being charted, management will get tired of it and let her go.

To be fair day and evening shift are extremely busy. (Yes, I know nights can be busy also, I worked nights for 17 years.) I hope I'm not as bad as the nurse in your situation but I will always prioritize patient care over charting, and to be honest my charting tends to be the bare minimum I can get away with.

I've worked second shift at a larger surgical hospital, and occasionally work day shift if they ask, so I know how busy it can get. Any admits that come to the unit after 1800 are the responsibility of the oncoming nurse to assess. There have been many times where I get the patient that came in at 1800, then turn around and get my own fresh admit at 1905 (Sometimes sooner, but some of the PACU nurses try to hold them until after shift change for us). If it was just those not done, it wouldn't be a problem, but she gets admits starting at 1000, with no patients prior to that, and still doesn't get her assessments done. It's frustrating, because if I have a patient who is sedated or has something going on, I'll do a quick look back at the previous assessment to see if it's a new occurrence. I've had to narcan patients just after shift change before.

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I've worked second shift at a larger surgical hospital, and occasionally work day shift if they ask, so I know how busy it can get. Any admits that come to the unit after 1800 are the responsibility of the oncoming nurse to assess. There have been many times where I get the patient that came in at 1800, then turn around and get my own fresh admit at 1905 (Sometimes sooner, but some of the PACU nurses try to hold them until after shift change for us). If it was just those not done, it wouldn't be a problem, but she gets admits starting at 1000, with no patients prior to that, and still doesn't get her assessments done. It's frustrating, because if I have a patient who is sedated or has something going on, I'll do a quick look back at the previous assessment to see if it's a new occurrence. I've had to narcan patients just after shift change before.

Gosh, this sounds like the nurse I used to work with!

I agree with what you are saying. It is very frustrating.

If a patient needs to be narcaned an incident report could be, should be, made.

Maybe, hopefully, management is trying to do something about it this. Keep that in mind.

I'm afraid you'll just have to let it go. Pray for her. Say "ohmmmmmm" and think of your happy place. Don't let her drive you bonkers. She isn't worth it. Smile and go about your business.

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You've reported it. If you just find it annoying that she is not pulling her weight, either you ignore it and worry about you or you look for a new job.

In cases where it actually impact pt care, you could write an incident report--as always, facts only and no names: "Pt has been admitted to the unit for 27 hours. No admission assessment has been charted." Rather than just getting that nurse in trouble, it may (?) serve to open some eyes as to an issue that is preventing nurses from completing the charting on time. If you go this route, it may come out that you are tattling on people, and you also have to be prepared for nothing substantive to come of it.

Also, I might have approached it a little differently, but I think it is appropriate to tell an orientee that pt care takes priority over charting 99% (100%?) of the time.

I don't think she should say "no ad assess charted", as someone could say, "Well, I did it and it appears to be missing".

I just can hardly believe the replies on here about how people aren't doing their charting.

I also don't understand why OP would be in trouble for not passing on info she didn't have.

I do know that OP needs to either leave it alone or make her exit, as the bosses have already approved this not charting baloney.

Some former coworkers always got their breaks and got off on time. I almost never took a break and never got off on time. I eventually realized that they were not charting!

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