question answered

JustEnuff2BDangerous, BSN, RN · Feb 28, 2010

I agree with the above posters. To take vital signs and not document them, especially to not document them because they are not ideal, could be considered negligent if something adverse were to happen because of it. That's the same scenario as a pt having a bp of 220/120 and you not charting it because they haven't received their BP meds yet. If the pt, God forbid, were to have a sudden stroke because of such high BP, and the last BP on the chart was 130/80, don't you think you'd have some explaining to do?

Your job as the RN is not to make your pts appear as healthy as you want them to appear. And by telling the aide to not chart abnormal VS, that's exactly what you're doing. Your job as the RN is to assess your pts and record your findings no matter what they may be. If your findings are abnormal, you document them, and then find ways to fix them (or explain them), and then document what you did and the pts response to that. It IS more work but it is certainly not redundant. What if something besides pain were going on? Then you'd have to do a good two hours of backcharting to explain what the original situation was and why you did all these interventions. You're the RN, not the director of nursing. The hospital has good reason for having policies in place the way that they are, and that is not to say it is inappropriate to question them at times, but issues with them should be brought up with your supervisor, not the aide. She's just doing what she has to do to protect HER job.

kathy313 · Feb 28, 2010

As a CNA, I charted all my VS, regardless if they were abnormal or not, they were reported to the RN, who would then assess the patient if need be. Yes, the information they gather is to be charted, if that is the policy within your facility. Any follow-up is on the nurse.

The aides I worked with when I became a nurse charted all the vitals taken, they could also do a patient note of who, what, when and where reported to. The point is, this was the patient VS at the time, anything else to be done is up to you....your responsibility. Were you uptight maybe because you'd have to go back and recheck the bp and do more charting? If the patient was in pain and you administered something for that, you'd have to go back and reassess the pain, right? So check the bp again.

roser13, ASN, RN · Feb 28, 2010

Interesting that you chose to delete your original post (which still lives on, by the way in quotes).

I hope that you didn't take our honest answers as attacks and by the same token, I hope you are able to your situation from a different viewpoint now.

allnurses Guide · Feb 28, 2010

I haven't read anyone's post that mentioned fraud. Of course those things that you note have an impact on VS. That's why ideally, VS are not taken under any of those conditions. But the VS were taken under one of those conditions and thus needed to be documented.
After all, if I read your post correctly, the increased BP was the only indication you had that the patient was in pain. Thus, taking/documenting that BP assisted you in your nursing assessment/intervention.

I was the one who said "almost like fraud" . . . or lying in a subsequent post and someone else mentioned negligence.

You simply cannot tell another person to not chart something.

steph

cherrybreeze, ADN, RN · Feb 28, 2010

Why would you have deleted your posts? Did you not like the fact that you were not agreed with? Argh, that bothers the heck out of me. You wanted feedback, and you got it; I won't apologize that it wasn't what you wanted to hear.

And you changed your username, so now it doesn't match the quotes? WTH?

loriangel14, RN · Feb 28, 2010

Why on earth would the OP think that gets to tell someone what can be charted and what can't? If that was the BP then that is what needs to be charted. You can't just manipulate the charted VS to make everything appear normal. It is everyone's responsibility to chart findings as accurately as they can. You can't just skip recording a high BP just because it is not convenient.