Seasoned Nurses Looking To Tattle?

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Specializes in medsurg, progressive care.

One of the nurses on my unit can be a bit overdramatic, so I've learned to take everything she says with a grain of salt. That being said, she once told me that several of the more seasoned nurses often look through everyone else's charting (assessment, notes, etc) to nitpick for mistakes and bring it up to management. I kind of brushed that comment off, because no one had ever said anything to me about my charting.

Until last night. It turned out to be a misunderstanding on the other nurse's fault, my charting was actually correct, but it kind of irked me that she looked for it anyway. I totally understand looking at other nurses' charting to see a timeline of events, but now I'm a little nervous about charting. Which is dumb because apparently these other nurses have always done this and I've never been approached about it by anyone, management or not, until last night - and I ended up being right anyway.

Any thoughts?

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Specializes in Emergency Room, Trauma ICU.

My only thought, other than it being completely inappropriate, is that it's a HIPAA violation. They have no business being in all those charts and if someone were to do an electronic audit they would have excuse for being in there.

I would bring it up to your manager, very inappropriate.

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I agree with the previous poster. Total HIPAA violation especially if it is not their patient that they are looking in the charts of. I would bring this behavior to the attention of your manager.

On a side note, some people just enjoy nitpicking and bringing others down.

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Specializes in Critical Care, Education.

Concurrent auditing is a long-standing and very acceptable method of quality control for nursing and other clinical services. So, we should never be surprised when someone is looking over our shoulder. I think the issue here is the INTENT of that scrutiny.

In my organization, preceptors and managers are expected to review all aspects of a new hire's job performance - including documentation. They evaluate the documentation to make sure that it is congruent with organizational and professional guidelines/protocols, P&P, etc. so they can provide constructive feedback needed to improve performance. This is NOT a HIPAA violation because access to the record is necessary for the organization's (education and training) operation.

But (big, big but) - if the review & critique is 'unofficial', mean spirited and unsanctioned ... this should not be tolerated. It needs to be called to the attention of the manager. The perpetrators should be disciplined appropriately.

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Specializes in medsurg, progressive care.

Thanks, everyone, for the reply. A little added information: she was the nurse who was receiving this patient for me. I admit I do go back and read other nurses' notes- but only for information, not to critique. I see what time they last bladder scanned a patient or if they got the patient out of bed.

This nurse is NOT my preceptor, and I've been off orientation for 5 months now. I already knew other people were reading my charting/notes because I've had multiple people compliment my charting- mostly PT and case management, sometimes a nutritionist or even an intern. As a former english major and a young person who is very computer-savvy, I am almost never worried about my charting. I just thought it was a little weird that she made a comment about it- and then was WRONG. If you're going to critique my charting, at least make sure what you're critisizing makes sense.

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Eh, let em look. It is hard to prove if someone is "auditing" or if someone is doing something else entirely that would be a HIPAA violation. And if it is the nurse that is taking over your patient, then they will look at the notes and charting. You know that you chart well. Let them look, and if it gets to be too much, I would think that because it is an EMR, a footprint is left as far as who is accessing charts. But again, the oncoming nurse who is taking over the patient CAN look through the chart, as well as the person who is doing audits of the chart. I would be really careful, however, if anyone starts asking you to change your documentation. THEN I would go to your supervisor as to what to do about that.

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Specializes in retired LTC.

I read others' documentation. Not with the overt intention to 'tattle', but I am ADON, supervisor, Unit manager, Staff Development, MDS/RNAC, preceptor - whatever, just pick one. Documentation is way different from nsg school to real practice charting, acute care is different from LTC, etc. And some nurses need guidance to make the change-over.

It's my job to see that documentation is complete & appropriate. I have seen notes that make my jaw drop. I don't want to see any nurse hang herself in her notes, nor put the facility in a bad light. There have been times I have had to go up the ranks with a problem chart entry. And I'm sure there have probably been times when MY documentation could have been better. I get brain-dead at times too.

An example - Nurse charts "O2 in use a 3L via canula. Lung sounds blah, blah, blah. Etc. etc. For all intents and purposes, it was a decent note, nothing special. EXCEPT, physician order is written for O2 at 2L. And my next nsg entry documents my running O2 at 2L, like the order is written. Any astute paralegal can catch the difference and a lawyer could ask why was the nurse running the O2 at 3L, not 2L. Was there a problem? What else was wrong? Did she alert the MD? Why did she take it upon herself to run 3L? Etc. etc. See where I'm going!?!

The nurse has just jeopardized herself, as well as the facility.

I used to have to do audits. Oxygen therapy was one of the things I audited. I made sure all our oxygen/nebulizer pts had orders written, tx was care planned, acuities counted, equip charged$, maint checked, equip dated & secured, etc. Same type of issues with Gtubes, foleys, etc.

And as supervisor, I was required to review incident documentation for my shift for completeness, details, etc. So I wasn't tattling'.

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Specializes in CCU, SICU, CVSICU, Precepting & Teaching.

Preceptors, charge nurses, nurse educators, managers and anyone on the Quality Assurance committee can and DO look at your charting. Even if you're off orientation. If I know that your patient is on CVVHD and I'd like to show my orientee how to document on CVVHD, I may open up your chart and show her. If your charting is in error, I'll pull you aside and tell you so, giving you the opportunity to correct it. You would rather have a preceptor, charge nurse, educator QI committee member tell you you've made an error in your charting that have a lawyer bring it up while you're sitting on the witness stand, wouldn't you?? If you're making mistakes in your charting, wouldn't you like to know how to do it correctly?

As a charge nurse who regularly has multiple new grads just off orientation on the night shift, I make a habit of going through their charting -- not to nitpick, but to ensure that I know what is going on with their patients. If I find mistakes, I'll let them know. As a preceptor, I co-sign every word that my orientee charts, so I make darned sure it's correct.

You're a new grad and terribly inexperienced. People are going to routinely look at your charting -- and that's a good thing. How can you correct mistakes you don't know you're making?

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Specializes in Emergency Room, Trauma ICU.

It's one thing for the charge nurse to check your charting, it's another for a staff nurse to go through your charting looking for excuses to pick on you. They are night and day. There are lots of legit reasons for someone to check your charting, none of them seem to apply in the OPs case.

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Specializes in Peds, Tele, ICU, ER, Orthopedics, Psych,.

Hi Rinskins,

Reading your post reminded me of recent incident I had recently with a nurse who is new to the ED. Granted she is not a new nurse (the ED requires 1year of acute care experience as a minimum requirement), but still pretty inexperienced in comparison to my 20 years of acute care, bedside nursing. Anyhow, I have taken report from this nurse in the past, and have noticed a few times that what she would tell me in report was not documented in the chart. She was busy in a patients room, so I started reviewing my patients charts to get a feel for what they were there for, and any current orders that needed to be done, and I noticed that one of the patients had been there for over 8 hours without a note, other than the initial note. I also noted that a nursing assessment had yet to be documented, and the last set of vitals had been recorded 6 hours ago.

Fast forward 5 minutes later, she is out to give me report, and when she gets to this patient she mentions episodes of hypotension, medication administration of narcotics, and so on, none of which was documented. So, I mention to her that none of that was in the chart and she immediately became defensive and hostile, asking "are you looking through my charting?" Let me also add two things, 1 - I have taken over in the past where she has one note for a patient in her care for more than 8 hours, and this is multiple patients, often they are drunk college students sleeping it off, but not always. 2 - I am the most sympathetic, calm, and non-confrontational nurse you are likely to meet in an ER, and I was very tactful and nonjudgemental in how I brought it up. I was tactfully trying to remind her of what every nursing student has drilled into their head, that "if you didn't document it, it wasn't done". Perhaps coming from the medsurg floor where they have an electronic MAR (which we have yet to implement for the ER) she was used to the computer capturing her response to patient change in condition that way. Anyhow, this exchange was witnessed by another nurse who is very much what I would term a whistle blower and it was brought to the directors attention. Apparently I was not the first nurse to have this issue with her. This nurse is now a bit better with her documentation.

So, having seen the majority of responses that jump immediately to HIPPA, why do you nurses who jumped to that conclusion think that your documentation isn't reviewed, and that if it is, it is a violation?

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There are people who are tasked to audit charting. At two facilities where I worked, they even had a sheet with "glitches" noted. However, there are also situations where coworkers peruse charting to nitpick someone they are targeting, as the OP described. Then, there are the times when something "interesting" happens and almost everybody wants to go to the chart to read about it. The inappropriate perusing of charting is just another example of people not following ethical rules of conduct at work. When you encounter this, you may, or may not, want to bring this to the attention of the supervisor.

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Specializes in Emergency Room, Trauma ICU.

If a nurse had no business being in the chart, as in the OPs example, that is a HIPAA violation. Looking at the charting on a pt you're taking over in is standard nursing protocol. Charge nurse reviewing charting is standard protocol. Snooping in random charts to snark at a coworker is actually a federal violation. That's why people jump to HIPAA.

And any ER pt who hasn't had a note in 8, even if it is a drunk sleeping it off, is bad form and needs to be brought to the attention of the nurse. I personally just started doing registry and make sure to tell the nurse who's breaking me to tell me if I'm missing anything in my charting. Part of nursing, in my opinion, is being open to constructive criticism.

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