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question about documentation

Posted

I am a new nursing student who took a job as a rn student and my preceptor does not seam to like me. I was in a pt room who would not wear their leads or the o2 sensor so I counted their heart rate with the radial pulse. Now my preceptor is trying to say I falsely documented a heart rate and respiratory rate because it was not on the monitor. I dont want to get in trouble but even time she brings it up I tell her how I did it and she said ya right u falsely documented. What do I do in this situation?

Edited by abells

TheCommuter, BSN, RN

Specializes in Case mgmt., rehab, (CRRN), LTC & psych. Has 15 years experience.

What do I do in this situation?
Since she's accusing you of fabricating vital signs, cover your behind by insisting that she be present whenever you obtain them. This way, she'll be able to witness you collecting the data. This may annoy the preceptor so much that she'll stop the accusations.

Alternately, insist that someone else be in the room when you check the vital signs. The witness can be anyone, including techs or another nurse. This will protect you from false accusations, although I suspect your preceptor is going to dislike you regardless of what you do. Good luck to you.

Thank you for the advice I am done training with her and going on to night shift training it just the other day when I left she stated because of that pt she does not know if she can trust my charting so she cant trust me as a co worker. I have tried to explain it 100 times I am just worried about getting in trouble because I really need this job because I pay for all my classes out of pocket.

Plus if she complains I am worried it will effect my CNA license and hurt me from getting my rn license because those are pretty big accusations

brattygrl

Specializes in Peds critical care. Has 15 years experience.

Talk to your nurse educator. She may be aware of issues with this preceptor and needs additional info to actually do something about it.

Even if no issues with her in past, you want to cover your butt!

What a bunch of baloney.

I suppose the patient was not competent to speak to your assessment techniques.

I would write a statement and sign it, take it to the nurse educator or other responsible supervisor and request it be placed in your personnel file to preempt the preceptor badmouthing you when it counts. Can guarantee her accusations will not go away. Be careful. She has warned you that she is your enemy.

You should have documented ® for radial pulse. If you did this, your preceptor could not be accusing you.

Crazy, how does she think staff get vitals on patient's on non monitored floors?

I really dont know. She only started it 2 weeks after I took care of that patient I took me forever to realize who she was talking about. She actually has harassed me to about using my own personal pulse ox on a pt because she cant see the numbers on the monitor. I had just started with this computer system so I was not even sure I just charted the heart rate.

It just make me worried that I will be fired for false documentation. because their are not too many hospitals in my area so I like to keep on good terms

Now it make me fear even know I am on a different shift she is going to try to come back after me when it gets close to my 90 days.

If I could remember the pt name I would go back I to the chart but for the life of me I cant remember and she had a very common last name so when you look it up you cant find her

Don't use your personal pulse ox. Don't use any of your own equipment. Your equipment is not calibrated by or maintained by the hospital.

TriciaJ, RN

Specializes in Psych, Corrections, Med-Surg, Ambulatory. Has 40 years experience.

Now it make me fear even know I am on a different shift she is going to try to come back after me when it gets close to my 90 days.

If I could remember the pt name I would go back I to the chart but for the life of me I cant remember and she had a very common last name so when you look it up you cant find her

Do not go back and do anything different in the chart. Even properly done late entry charting looks like an admission of guilt if you've already been accused of something.

Is there an instructor or charge nurse who can mediate? You might want to suggest a 3-way meeting so you can look your preceptor in the eye, with a witness present and say clearly: "I did not falsify any vital signs. If I did not follow protocol in taking them, I will take that as a learning experience. Please explain unit policy to me about the taking and charting of vitals so I don't make that mistake again. I take patient care seriously and I take my reputation seriously."

Dealing with this head-on in a professional manner should put the non-stop snide allegations to bed. Good luck.

Do not attempt to go back to that chart! Get with a supervisor to help you but don't access the chart on your own. From now on when something is not according to Hoyle, verbally inform a nurse, make note of who you informed about what and look for another place to make a written record so that you have a paper trail before an accusation.

I wonder of I have truly anything to worry about since she just keeps saying it but I have not been approached by any of the leads or the manager

corbinRN

Specializes in Pediatric Critical Care. Has 5 years experience.

Yes, I would tell your nurse educator and manager of the floor you work on before she does. It would sound better hearing it from your first.

Thats the bad thing I am on night weekends now so it very rare I see the nurse educator. And I know in my heart I did not do anything wrong of I was wrong I would admit it, but u dont need technology to get a heart rate and respiratory rate. With this I get praised by all the other rn and leads about how wonderful I am and the great job I am doing after 4 weeks. I rather not bring something up that does not need to be because its dumb stress on a unit that runs short staffed with I 5 to 7 pt per nurse because ever one has left

The only thing you wouldn't be capable of measuring yourself is the 02 saturation. Just so long as you documented somewhere that the patient refused the 02 sensor. I also wonder if she always trusts the monitor... IMO the respiratory monitor is never 100% accurate.