Should I have Not documented?

[NurseLoveJoy88, ASN, RN]

Background: Im working 3-11 shift and at 10:00pm the aide tells me that mr.b have not voided so far this shift. I go to assess resident at 1030 p and find a wet soiled diaper. Bladder is non palpable, no acute distress no pain. Does have poor fluid intake but we do encourage him to drink. So I document what was reported to me, my assessment findings and current status of resident. lo and behold my don told me I should have Not documented anything. Im still confused about this . please help!!

[jbudrick, MSN]

You did the right thing by documenting the aide's report and your findings in my opinion. The DON would probably be telling you something different if it was reported to her that the aide told you that the patient had not voided and you did not address the situation. Hindsight is always 20/20. Best wishes with your job.

[mesa1979, BSN, RN]

Always document! It's your license not hers.....

[jackierocks]

I am a new grad and recently experienced something similar. Here are my thoughts:

1. document everything until I am experienced enough to omit something I am 100% is non-threatening to pt. well being

2. it's your (my) license and anything were to come up documentation would show you recognized an issue and took action.

3. don't let a don bully you. you have a brain in your head and heart in your chest, follow your instincts.

'hope that helps.

[cherrybreeze, ADN, RN]

What was your DON's reasoning for saying you should not have documented anything? I can see why it may not have been NECESSARY, per say, but I don't see any HARM in having done so...

[mamamerlee, LPN]

I'm curious as to what you documented. It should have been something very simple - '1030pm ms so+so cna, reported that pt had not voided this shift. Upon checking this pt, this nurse found he had voided and had a bm. Aide states she had last checked this pt at 1015'

I think the concern here from the DON was that the pt had not been checked for hours, or that since the pt had actually voided this amounted to a non-issue.

In my opinion, you did the correct thing.

[katkonk, BSN, RN]

What was your DON's reasoning for saying you should not have documented anything? I can see why it may not have been NECESSARY, per say, but I don't see any HARM in having done so...

I agree with the above poster. What was her beef with the documentation? As long as you documented only facts, and no subjective opinions re: the report or the person who gave it to you, then it is valid. You should not be called in because of documentation that notes an action taken. And, it should work to the facility's advantage to know that a corrective action has been taken, and the patient assessed for problems. If there is a pattern of this behavior with this CNA/aide, then that would be even MORE reason to document the situation.

[buzkil]

Sounds like you documented the aides assessment, then yours. Yours is the only one that counts. Maybe that's why your DON said something.

[cherrybreeze, ADN, RN]

Sounds like you documented the aides assessment, then yours. Yours is the only one that counts. Maybe that's why your DON said something.

Well, the aides don't document their findings, so I don't think it's inappropriate to document when you are told something by a CNA. "CNA reported to writer x, y, and z. Writer then blah, blah, and blah...." I have done that plenty of times. You have to have a point a to get to point b, and often it is by the report of a UAP.

[Meraki]

I agree with the others. What was different about this charting that made it stand out to the DON? Do you normally chart who voids and when? Was this voiding pattern for this day different for this resident? - what is normally charted about his voiding? Was anything in your charting about the CNA's actions rather than about the resident or subjective? Did you write a lengthly paragraph about something very minor?

If this is something you normally chart or you had concerns because it was atypical for this resident then I don't know why the DON would have an issue with it. Unless I was concerned or monitoring this residents voiding I probably wouldn't have charted this but if I had I might have written....CNA (A.B) reported to writer at 2200 that resident R had not voided since the beginning of shift at 1500. Writer assessed resident at 2230 and noted resident had voided at that time. No distention or pain noted on assessment.

[caliotter3]

I was once told this little gem by the shift supervisor, "If you don't intend to take any action about something, then do not chart about it." Not getting into the wisdom of failing to take action, I could see the practicality of that statement. It does not make sense to chart something and then acknowledge that you did absolutely nothing about it. That seems kind of like shooting yourself in the foot.

I also see nothing wrong with what you did. Your DON probably was operating under the assumption that you shouldn't be bringing any kind of attention to something or somebody if you can help it. Sort of like, "Don't ask for trouble by doing extra charting" or an extension of what the supervisor told me that time. Like, "let sleeping dogs lie".

[NurseLoveJoy88, ASN, RN]

Thanks everyone! The don felt it was not necessary to chart anything. The aides do document on bms , skin condition, intake and etc. At my facility aides are famous for reporting findings to the nurse, and telling the don that we dont ever follow up. I just wanted cover myself and make sure we monitor the resident. I dont have much experience so Im learning what charting I should omit...