myac

Recently at my hospital I received a letter stating I have 3 doses of Ativan that were "not noted" and was told if I don't straighten it out then I will be reported to the state. I was was able to go back to that patients chart and print the mar that was scanned to their records, and find each order of Ativan for each dose I gave. I documented each administration and there are active orders for each. Im not sure if it's because I'm at a teaching hospital and residents and physicians are still learning and CHANGE ORDERS BY THE MINUTE or if it's a glitch in the system. Still makes me nervous. And in another note has anyone ever forgotten to document a med? In the midst of all this I remembered I forgot to document a GI Cocktail in the mix of things. I verified in via computer and the time I pulled it is in the Pyxis but I don't think I hand charted ☹️ Tough being a new nurse and learning while having to babysit residents and be their safety net !