Today we were in a different hospital so we were on "observation" only protocol for a L&D Hospital. We were each assigned a nurse to follow and then followed them to do their assessments in the morning. I followed my nurse to her patient's rooms and watched their assessment techniques and wrote some notes down for our following day where we will be doing assessments.
For our patients we are assigned we are to complete data packets. Nothing huge - I mean it's a lot - but it's more searching and digging through the computer to find the information to come up with nursing care plans. Well when I went into the patients charts I had been assigned I noticed that the nurse had input blood pressures and pulse vitals. The problem is the nurse didn't do these things. Not once did I see her pick up a blood pressure cuff, and not once did I see her taking the pulse of the infant or mother (she listened to their hearts but wasn't looking at any form of time clock).
I thought maybe it was an error, but then when I checked on my other patient I noticed the same thing. I witnessed these assessments. And we come on the floor right as report is being given so I know she didn't do these things before I came, and I shadowed her all day, so I know she didn't do them after.
I know she acts under her own independent license, but I feel really uncomfortable witnessing something like this and then seeing the documentation in the computer. What if something was wrong with that patient and I'm on as one of the individuals that provided care for that day? I don't want to take the fall or risk my future license because of false documentation.
Has anyone else run into this? Should I tell my instructor my concerns?
I know this is normally not the case.. but still.. I'm working really hard for my future license. I don't want to mess it up.
I wish I could say this was unusual, but what I have seen as a clinical instructor would make your heart stop. Usually I told students to bring these issues to me, and I dealt with the appropriate supervisor nurse to nurse. I have witnessed, the magical self-changing drsg, the medication charted at 0900 and found in the Pyxis at 1600, bilaterl pedal pulses on a unilateral BKA, and fundal checks on a postpartum hysterectomy. Talk to your instructor without making any assumptions or accusations. Sadly, not only are nurses run ragged, but many are far too ready to cut corners due to their own laziness and then tell students "this is how it is in the real world". It isn't if you are a decent nurse.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I noticed this past rotation on occasion they would put the best of what they saw. Like, if we were called into a room because a PCT noticed an O2 in the 80s, but after a minute of the patient stopping activity and doing nothing but breathing, it would go back up to low 90s. I didn't question it, but it bugged me. Wouldn't it be important to put both numbers? Also pain. If someone says they are having intermittent but moderate pain, wouldn't it be good to document it? My recent facility doesn't because it triggers some sort of investigation if there isn't an intervention for pain, even though the person says the pain wasn't happening that second. This one I did ask about, and while I understand not triggering protocols, isn't it important for providers reviewing the chart to see that there is an issue of pain? IDK. My final conclusion was that this is a new facility for me, I am very, very new to all of this, and I really don't know all of the reasons for all of the things that happen. My job was to learn and observe.
This would depend on the patient. If the patient is known for low O2 sats with activity and they have a room full of visitors or the are fussing in the room. Going in and telling them that they need to be mindful that they re healing and need to curtail their "normal" stuff until they feel better is OK. I will always document it and the conversation with the patient but I am very anal about that stuff.
I would document intermittent pain and what aggravated it. Some nurse don't...not the best idea but it will be their behind if it goes to court for some reason.
Learn the proper way to do things. and practice the accurate way when you graduate. don't fall into these lazy habits.
I am a health care tech and I work at a large adult mental health facility in Des Moines. Cameras are placed all over our unit and are motion recorded at all times. Throughout the shift we "round" on patients every 15 minutes. The director has stated that this is one of the most important things we do to ensure patient safety. The director has also stated "that if anything is done that violates the safety of the patients, it should be brought to my attention." I witnessed two different occasions when two different health care techs falsely documented the locations of patients. I had witnesses and a time frame. I know this because the health care techs were not on the unit at the time they documented the locations of the patients. I informed the charge nurse and the director. I am confused. I am under the impression this action would result in my termination if I did this. I understand that my supervisors are not obligated to inform me of the disciplinary action taken regarding other employees. While reporting other violations that I felt met criteria for safety violations (sleeping while on duty). I was told to do my job, not to worry about others, that groups or individuals have reported to human resources that I was targeting certain employees. I was also told to be careful.
When I was on the L&D unit all the laboring moms were on continuous monitoring, that included their BP (cuff stayed on them) and pulse. Their history was automatically saved, and could be accessed at any time in the computer or the bedside monitor. If you were in doubt, you should have ASKED the RN before just assuming that she falsified the info. L&D nurses tend to be very protective of their moms, I doubt they would put a mom and baby at risk by falsifying info.
I think in L&D they normally have blood pressure cuffs on and they have fetal heart monitors on. Our charting system in the ER is "smart" enough to find out that patient is in X room so look to see if there is X monitor. It will pull vitals from X monitor and just need the nurse to validate. Then we also can have nursing techs do the vitals if necessary.
trishmsn
127 Posts
I wish I could say this was unusual, but what I have seen as a clinical instructor would make your heart stop. Usually I told students to bring these issues to me, and I dealt with the appropriate supervisor nurse to nurse. I have witnessed, the magical self-changing drsg, the medication charted at 0900 and found in the Pyxis at 1600, bilaterl pedal pulses on a unilateral BKA, and fundal checks on a postpartum hysterectomy. Talk to your instructor without making any assumptions or accusations. Sadly, not only are nurses run ragged, but many are far too ready to cut corners due to their own laziness and then tell students "this is how it is in the real world". It isn't if you are a decent nurse.