I'm an RN and was hospitalized for a few days recently. The hospital staff did not know I was an RN. Towards the end of my stay I asked one of the nurses to look at my chart. Being the curious George that I am, I looked at the nursing narrative and was shocked (alright, shocked is a little over the top, surprised?) at how many lied about assessing "this" or assessing "that" and/or the activities they perfomed. Some said they inspected my skin for bedsores, some said they assessed my wound, a couple said they provided me some education, some said they assessed my pedal pulses, one said they did catheter care (I didn't even have a Foley!). The amount of lying that went into the documentation was quite astounding. It wasn't just one particular nurse, it was most of the nurses. It was as if they were pulling things out of mid-air. This posting has no other purpose other than to share my experience. I always chart what I actually do... call me old fashioned. I didn't mention anything because I know how busy the job can be, and I'm not one to cause commotion if it can be avoided. I know that it is possible to mix up patient care, but it occured way too frequently to be a mix up.
I agree, checklists can cause mistakes. I was in nursing school back when we all wrote a narrative at the end of our shifts. Blue ink for days, black for evenings, red for nite shift. Ahhhh...those were the days! We all had Bic four color pens! That's when nurses still did bedside care. A perfect time to assess almost everything was when you were bathing them. I know times have changed but we need to be so careful. Every checkmark can/will be challanged in a court of law if needed. I'm just surprised that a patient was allowed to view the chart. It's my understanding that it is not within a patients right to look at the chart. I am the keeper of student records in a school and no one is allowed to view them without written request and then they can only view them in my presense. They may not make copies. I guess I'm old school and I always go by the book. Sad to think nurses are unethical or dishonest; politicians sure, but not nurses!
Specializes in Cardiac, Hospice, Float pool, Med/Peds.
This is why I love our all computer charting... I take my computer in with me and chart as I am doing my assessment or as soon as I walk out the door... I try to chart right after each assessment, if at all possible, and if not, then I make notes on each patient so I am not falsifying the chart... not a good RN at all to do that... ;(
i haven't checked my own charts for charting errors, but 3 out of 4 hospital vists results in me recieving a medication in error, or not recieving a med as the case may be....I ahve been anurse for along time and sincerely hope we don't ALL make that many mistakes!!!!!
But aren't there things that you don't have to directly assess if other things are there? for instance, if your patient just had a big BM independently, she probably does have bowel sounds. If a 35 year old is in for nausea/vomiting and been hopping around the unit all day, she probably has pedal pulses. A 40-year old with MS who was on his computer on cell phone working all day is most likely aox3.
My biggest pleasure however is reading MD's notes. In our system they write narratives. It is always interesting to learn that a patient with +2 pitting edema has "no edema", a person with 2 stage 3 wounds has "intact skin" and a disposition on a dni/dnr patient is "full code". I see people time and time again walking inti a person's room for 1 minute, never lifting the blanket, quickly listening to lung sounds, and then proceeding to write a long note with full assessment.
Just this past night I admitted a patient with 4 big necrotic wounds on the leg and 2 sacral ulcers, one of which was a 7x9 cm stage 4. The admitting doc's note only mentioned 2 wounds on the leg, and "skin otherwise intact". If I did not document than I guess Medicare would assume that patient aquired the sacral wounds during the 6 hours under my care.
My biggest pleasure however is reading MD's notes. In our system they write narratives. It is always interesting to learn that a patient with +2 pitting edema has "no edema", a person with 2 stage 3 wounds has "intact skin" and a disposition on a dni/dnr patient is "full code". I see people time and time again walking inti a person's room for 1 minute, never lifting the blanket, quickly listening to lung sounds, and then proceeding to write a long note with full assessment.
LOL, I love reading some of these notes after certain residents round. For example, say a patient hasn't been on sedation for a couple of days (they are, in fact, comatose). Doctor rounds and writes "patient remains on Versed gtt" umm... no, they are just unresponsive!
Or here's another one of my favorites "lungs clear to auscultation" and I saw them in the room and they certainly didn't listen to the lungs, nor did they read my notes to know whether or not the patient's lungs are actually clear.
PattyB RN
23 Posts
I agree, checklists can cause mistakes. I was in nursing school back when we all wrote a narrative at the end of our shifts. Blue ink for days, black for evenings, red for nite shift. Ahhhh...those were the days! We all had Bic four color pens! That's when nurses still did bedside care. A perfect time to assess almost everything was when you were bathing them. I know times have changed but we need to be so careful. Every checkmark can/will be challanged in a court of law if needed. I'm just surprised that a patient was allowed to view the chart. It's my understanding that it is not within a patients right to look at the chart. I am the keeper of student records in a school and no one is allowed to view them without written request and then they can only view them in my presense. They may not make copies. I guess I'm old school and I always go by the book. Sad to think nurses are unethical or dishonest; politicians sure, but not nurses!