"Document! Document!! Document!!!"

It's another late night and I'm thinking of a topic which might have some cool responses (I hope). The title of my thread is our favorite phrase. We repeatedly say document everything. So my 2 part question is:

Part 1: For situations where you are being verbally abused by a coworker, or feel you are being set up by management/coworkers, or for staffing issues, where do you document this? Obviously you can't make a note on a pt's chart that you had to take care of 8 pts and list off what you did to get the situation handled. So where did you write this information? For example, do you keep a journal where you can add entries whenever, or do you write down situations on your personal report sheet, or are they spread throughout this bulletin board?

In this regard, I would document in detail patient safety was at risk addressing everyone involved. Follow the chain of command. If your union, I would file a workload grievance along with your detailed letter.

Part 2: When has an instance of you documenting something which "just didn't seem right" about said situation save your butt from getting fried by administration, a lawyer, or the BON?

Nothing as serious like that, but I documented that I verbally instructed a pt. on the care of a leg bag. We had no written discharge instructions left to hand out (which I documented too) and his s/o (who is a RN in an acute care setting) wrote a letter c/o they weren't issued any discharge instructions verbally or written. Charting is very serious. I chart everything and anything.

1. I have written up things in my word program to my DON and Administration having to do with co-workers. I put it into letter format (business letter format), with the most important thing being the old CC (or carbon copy) at the bottom listing the names of the people I sent the letter to (keeping in mind you should but YOURSELF on that list or a phrase saying you are keeping a hard copy for yourself. Say hard copy because some places have rules about having any names or information about work on your computer...).

I stick to JUST the facts, and how the action made me feel. I use quotes as much as possible, and all actions/implementations. You may even want to do it in SOAP format to keep it flowing and to the point. Make it brief but to the point...don't add a bunch of things that are not needed or repeat yourself. I find it best to write it...walk away for a while and then edit till you get it right.

Then the most important part of all...actually giving it! That is always up to you, if not it is good therapy or you can keep that letter in case of other probelms and add to it.

2. I had to do this once when a client belittled and totally hurt a Caregiver I had who was of color. It was horrible and it wasn't like I was going to put this little converstation on the charts (I did make a comment as to a broad nature and scope of the conversation in the chart for future reference since it was a change in this persons behavior..but not indepth as my letter to the administration). My caregiver wanted to quit, and if she didn't show up to work or quit...I wanted the administration to know why, and maybe think carefully about having future caregivers of color working with the lady (not fair to my caregivers, or at least they should be warned that this old lady has some issues that are not likely going to change at 90~!).

I also JUST had to do this for a caregiver that is nit picking and trying to get another one fired by pointing out EVERYTHING she sees and blaming the other...most cases I found to be totally wrong (the accused wasn't even on duty!), and the administration didn't take the time to research...well believe me they will now! Helps to have three nurses on your side (the accused is an AWSOME caregiver, should go for nursing really, but the other wants her position on the day shift, only way to get it...get the other fired...not right!).

If you do nothing...nothing will be done. And watch for that...sometimes we get into lots of trouble if we see something and don't act!

If it is not pt related, but things are just "not right", keeping a journal is fine. Document who, what, when, where, (just the facts!!) w/ exact quotes for conversations - right it down ASAP after the incident. Sign and date it.

If things are more than "just not right", you need to let your immediate supervisor know, same rules as above, indicating you are keeping hard copy for yourself. Previous poster covered this well. I've also "cc: file" to indicate hard copy w/ me.

Keep in mind, tho, if you keep a "journal" and it is used, it could be considered a legal document, so make sure what you write is as accurate as possible.

SJ