question about documentation

Nurses General Nursing

Published

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?

Specializes in Psych, Corrections, Med-Surg, Ambulatory.
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.

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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.

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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

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Specializes in Pediatric Critical Care.

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.

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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

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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.

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What I learned is a lot of people will stand in the door way and auto chart because out system links to the monitors and they input what is on the monitor

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So just a update I spoke to the nursing manager and found out she had tried to late but due to her seniority she did manage to get me in trouble. so instead of being icu certified they are leaving me in general floor care because they believe in my work but they also believe in as having her as my preceptor it hurt me because she was not even trying to train me correctely

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Specializes in Peds critical care.

Please tell me they didn't have you sign a write up...

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