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Discussion

Nurse documents a lie

I work in community and visit patients to educate them and keep them out of hospital. I recently had an issue with a nurse who documented on the patient record that I advices the carer to use the same wound care tray when doing the patients dressing...... Now I have never told the carer that... as matter of fact I told the carer to make sure you wash your hands to do the dressing using sterile gloves etc..... now I opened the patients chart and read that I told the carer to use the same tray on the patients chart.... my question is....are we allowed to write accusations in that manner?? Rather then writing according to the carer etc..... she wrote the primary nurse told her to use none sterile field.... am I exaggerating this or what should I do?? Advice please

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    • Expert

    Write an incident report, turn it in and keep a copy. See the boss and hash this out. I would also cover myself with appropriate teaching and documentation next visit unless the boss tells you to do something different.

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    • Expert

    I'm very confused. Are you a nurse? Is the carer an aide of some sort? Who is doing the dressing changes? If anyone is using the patient's chart to make accusations against other staff members, that is a definite no-no. If that is what is happening, please show the chart note to your supervisor.

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    • Author

    The carer is patients private hired none health care professional we the community nurses and the wound care nurse do the education. The person who made this accusation is the wound care nurse.... the fact that she wrote this in the patient chart which deformation of character and totally unprofessional..... I am just really upset the wording indicated basically incompetent.

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    • Author

    Thank you for the advice I will do that

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    That is one of those things that I feel should not be in the patient's record. Should something go wrong and your organization is sued, that will be scrutinized. As was said, write an incident report and get management to resolve this soonest.

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    I would speak to the "carer" about what I did instruct/educate and let them know I am documentation a clarification of what I did. I would let my supervisor know what I did in case it comes up and leave it at that. It maybe just a communication issue, no problem. If it is not you have made it clear what was provided. If they go back and do something else I would then take it to my supervisor with the documentation and ask them to handle it because what "I" did is not working.

  • Quote
    The carer is patients private hired none health care professional we the community nurses and the wound care nurse do the education. The person who made this accusation is the wound care nurse.... the fact that she wrote this in the patient chart which deformation of character and totally unprofessional..... I am just really upset the wording indicated basically incompetent.

    If the caregiver is not a healthcare care provider, how can they be advised to do* anything * in a sterile manner?

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