"Unusual charting"

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I found some very "unusual charting" when I was looking over the nursing notes on one of my private duty patients.

One of the nurses was doing what sounded like " her own opinion charting." She charted that the nurse on the previous shift had left the patient full of dried sticky BM.:eek:

She also charted that she found it "very disgusting" that there are not enough dressing supplies to do the wound treatments properly.:eek: She charted that the other nurses are always leaving this patient unshaved and unclean and that these nurses need to start doing their jobs.:eek:

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I would not hesitate to bring this to the attention of the nursing supervisor. No sense in trying to have a nice nurse-to-nurse chat with her, she most likely is not the sensible type. Furthermore, she should have already turned in the hard copies, so my question is to query the nursing supervisor if anything has been done and does s/he want you to bring the field chart copies to the office so they can be replaced when the nurse does appropriate charting. This is the type of stuff litigious clients love to get their hands on.

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Thanks. The hard copies are in the chart now at the patient's home. They remove the hard copies of the nurses notes every 2 weeks. The supervisor and I are not the best of friends. However, she is now giving me steady work. She is the type who doesn't like to hear any kind of complaints about anything. She doesn't want to be bothered period. The last 2 nurses who dared to complain to her about a patient being verbally abused were both taken off the schedule for 30 days as a punishment. :down:

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I would not hesitate to bring this to the attention of the nursing supervisor. No sense in trying to have a nice nurse-to-nurse chat with her, she most likely is not the sensible type. Furthermore, she should have already turned in the hard copies, so my question is to query the nursing supervisor if anything has been done and does s/he want you to bring the field chart copies to the office so they can be replaced when the nurse does appropriate charting. This is the type of stuff litigious clients love to get their hands on.

Yes. I bet the lawyers would love to find these hard copies.:lol2: There has been fierce competition for hours at this agency. I think the nurse who did all of this "unusual charting" is hoping that her supervisor will read these notes and will finally realize that she is the only "super nurse" and deserves to have many more hours than anyone else. Unfortunately, I think she is going to get a "wake up call" when the supervisor finally reads her notes.:eek:

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Specializes in Med-Surg.

I don't think you should approach it as complaining...

I think you can kill two birds with one stone in this situation. I would approach your supervisor and say something to the effect of:

"Hi ___________, how are you doing today? I know you're really busy, I just wanted to stop by and give you the heads up about some unusual charting I noticed while caring for pt. ________. I thought that your experience and insight might be valuable."

I little friendly "I'm on your side" butt kissing and letting her do the legwork finding the issue will remove you from the situation enough that you aren't complaining per se, only raising a legitimate question and letting her use her "expert opinion" in how to address the problem.

Or just say nothing haha, your choice.

-Dennis

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Those kinds of comments are even out of line for the communication book, where they should have been recorded anyway. There are ways to say something in the communication book without making accusations and drawing attention to the fact that a patient is receiving substandard care. Totally agree with your take on her motivation. Too bad, this type seems to proliferate in extended care. The supervisor sounds like a gem. In that case, say nothing, but keep a mental note to keep your own back out of reach from both this nurse and the supervisor. Neither are playing above board.

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I don't think you should approach it as complaining...

I think you can kill two birds with one stone in this situation. I would approach your supervisor and say something to the effect of:

"Hi ___________, how are you doing today? I know you're really busy, I just wanted to stop by and give you the heads up about some unusual charting I noticed while caring for pt. ________. I thought that your experience and insight might be valuable."

I little friendly "I'm on your side" butt kissing and letting her do the legwork finding the issue will remove you from the situation enough that you aren't complaining per se, only raising a legitimate question and letting her use her "expert opinion" in how to address the problem.

Or just say nothing haha, your choice.

Great advice.:yeah: Yes in today's world if you want work you better be a good butt kisser. I am afraid to even speak with this supervisor. Some of the nurses always show up late. I mentioned it very gently to her. Big mistake. Apparently those "late nurses" are her "favorites". I was not called for work for 3 weeks.:mad: So now I understand that if I want work I had better remain silent

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It wouldn't hurt to look for an agency with a more fair distribution of work and give them your attention. You would not be missing the lack of work and show of favoritism.

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Specializes in Peds/outpatient FP,derm,allergy/private duty.

I haven't seen that in the nurse's notes but that spiral notebook used to contain some real doozies, (as they say) with lots of capital letters, exclamation points, and unusual symbols scrawled across the lines of the paper and words underlined four or five times. Once I saw "you are a BAD GIRL !!!!!!!!!!!!!!" (these two didn't get along well)

Another one wrote "if you want something done why don't you do it yourself???!!!!". sigghhhh . ..I suppose that's better than allowing free-floating hostility to make into the patient's permanent medical record.

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Specializes in Hospice / Ambulatory Clinic.

I would be like I noticed some discrepancies in that charting that do not accurately reflect the high quality of care that we provide. I feel that this kind of charting opens the agency up to potential litigation even though the standard of care has been meticulously maintained. Can you please brief this nurse to let her know at this agency we are team players.

Always use the words we and us. Align your supervisor to you side first

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Specializes in Hospice / Ambulatory Clinic.
It wouldn't hurt to look for an agency with a more fair distribution of work and give them your attention. You would not be missing the lack of work and show of favoritism.

Do those even exist? If the scheduling was done by robots then maybe

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It wouldn't hurt to look for an agency with a more fair distribution of work and give them your attention. You would not be missing the lack of work and show of favoritism.

Yes, in December I will finish one of my computer classes and my IV certification class. I am going to apply everywhere I can in December. Hopefully I can find a normal agency somewhere? :confused: Or do they even really exist?

I sure hope I can find at least one normal agency in this town. All I have met here so far are LIARS.:down:

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