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Discussion

Question for you.

I work in a mother-baby unit that all moms (unless baby is a NICU baby) room in. Most of our pedis come early in the morning, right around the time I am doing morning assessments on mom and baby. My question is, if you stand there and watch a doc do a good assessment (not just where they listen to the heart and run) do you then turn around and do another complete assessment on baby? I am pretty new to this area (all areas really, I graduated in Feb.) I have been politely waiting til the doc leaves and doing another assessment, but the moms get worried and ask why I am doing it when the doc just did it, and I sort of feel like I'm not going to see anything that a doc who did a good assessment wouldn't, you know? I was just wondering how you guys would handle this, any opinions are appreciated.

Featured Replies

I always do my own assessments. There are some nurses on my unit who, when admitting a patient, will take the medical student or residents assessment and then chart their findings.

I do my own for two reasons.

1. I only chart what I do myself. Part of my nursing role is to assess the patient.

I may not agree with the medical provider's assessment.

2. Even if everything is normal, if something should change later in my shift, I need to know what the baseline was.

I would explain it to the parents that I need to asses for myself so I am familiar with their baby. You can also use your assessment as a teaching moment to help them become familiar with their baby.

I always do my own assessments. There are some nurses on my unit who, when admitting a patient, will take the medical student or residents assessment and then chart their findings.

I do my own for two reasons.

1. I only chart what I do myself. Part of my nursing role is to assess the patient.

I may not agree with the medical provider's assessment.

2. Even if everything is normal, if something should change later in my shift, I need to know what the baseline was.

I would explain it to the parents that I need to asses for myself so I am familiar with their baby. You can also use your assessment as a teaching moment to help them become familiar with their baby.

Thanks, PegRNBSN, for saving me the trouble of typing out the exact same thoughts.

Your assessment is done so that you have hands-on familiarity with the baby. That way, you can chart what you have seen and heard.

Think of it like a court of law. Anything someone else assesses is "hearsay."

Besides, with med students and residents, depending on their level of experience, you may very well catch something they didn't.

  • Expert

Many many times I have found something that someone else missed (MD, nurse, med student, whoever). The shoe has sometimes been on the other foot as well. It's really important to know what's going on with that baby that moment, should something change, like has been posted already.

We have to do VS every shift anyway. While you're doing that, you might as well go ahead and assess the baby. Not a great big burden, IMO. I like Peg's explanation -- you're assessing so that you are familiar with their baby, and invite them to see what you're looking at.

  • Author

Thanks for all your feedback. I feel better knowing that I am not doing something that is unnecessary. I work 12s so we end up doing 2 VS and assessments on each shift. Thanks for the tip on incorporating the parents into the assessment. Great idea!

Thanks again

Your own assessment is never unnecessary and don't ever be bullied into thinking that is wrong.

I'm surprised you weren't taught in your program to incorporate the parents into the assessment experience. I have my students do this (though most do it with trepidation [what if I can't answer the parent's questions?]). I tell them that the sign of an educated person is not that they can answer all the questions, but that they know where they can go to find answers.

  • Expert

Imagine you are giving a deposition or testifying in a courtroom, and you are asked about your assessment of the patient. How is it going to look when you state that your charting really mirrors the assessment done by somebody else, even if it was the doctor? Always, always do your own assessments.

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