I'm an RN, now FNP x 5 years with over 15 years of ER/CCU and ICU experience. Is it old fashioned to expect RNs to do a full assessment at the beginning of their shift?
I have a colleague/NP friend who has been in the hospital now x 1 week. I will spare the details, but she was admitted, discharged, admitted urgently to another hospital and then transferred back to the original hospital. In her whole WEEK of admission, she says just ONE RN and one MD even put a stethoscope to her back. A pleural effusion was MISSED because no one did this basic assessment. Is this the norm now? Do med/surg RNs chart their "make believe" assessment every day?? How do they do this and just flat out lie every day without being caught ? She spoke up at first, but soon tired of feeling like some crazed out NP who was being so picky about her care. She thought it would be interesting to see who would and who would not do an assessment. She says the new RN will come on shift, say hello, walk up to the in room computer and start charting a bunch of notes, pass meds and then continue with the same pattern all day. No bowel sounds auscultated, no lung sounds auscultated. Magical patient care without touching the patient !! This is at a pretty major size hospital too in a major metro area. I have to say I experienced something similar a few years ago but not nearly as bad.
So you are comfortable with the reality that your false documentation could harm your patients?
Charting dishonestly is acceptable to you because you believe doing so is necessary for your job security? The continuance of your salary is more important than your professional and ethical responsibilities to your patients?
Do you not practice ethics in your personal life? Did nursing school not teach you about your great responsibility to patients and their families; that your professional duty is to be truthful? How can you advocate for your patients' well-being when you are documenting dishonestly?
Please take time to think long and hard about what you are doing. Most nurses on this thread find falsely documenting patient care to be reprehensible, and find failure to properly assess patients inexcusable. Please think about what is at stake for patients and their families, who are trusting you to be acting in their best interests, and are relying on your accurate assessments and documentation of care. Think about the rest of the team you are working with, who are also relying on your documentation in their actions with patients. It is appalling to me that you put your own needs above your patients.
Unless you are going to start supporting her, your pearl clutching is unfounded at best and perhaps shows how out of touch you are with the realities of bedside nursing One nurse's 100% honest documentation is not going lead to some epiphany on management's part to start staffing the unit differently or otherwise improve the workflow. I got news for you, they already know the documentation is fudged and they want it that way.
Unless you are going to start supporting her, your pearl clutching is unfounded at best and perhaps shows how out of touch you are with the realities of bedside nursing One nurse's 100% honest documentation is not going lead to some epiphany on management's part to start staffing the unit differently or otherwise improve the workflow. I got news for you, they already know the documentation is fudged and they want it that way.
But we're not talking about honest documentation, are we? Your choice to practice dishonestly. I don't/won't. And I do my best to protect my family members from care from people who practice dishonestly/unsafely. One nurse on this thread detailed how his/her father died because bowel sounds were charted as present when they weren't. Another nurse, who recently had surgery and was in the ICU, experienced no assessment of bowel sounds. Yet another nurse had to instruct her caregivers in the emergency room how to take care of her. And then there was the OP's friend. Just a few instances of how actions have consequences.
Not providing necessary care, and charting dishonestly, can have serious consequences for patients. It's easy to fall into the trap of thinking that "oh, it's just a small omission, or a small lie." Charting lies has consequences for the whole health care team, not just the patient. Quite possibly the nurses who didn't auscultate bowel sounds in the instances above didn't believe their actions could have serious consequences, if they ever found out about them. The patient dies, or is discharged, and it's their problem and their family's.
Unless you are going to start supporting her, your pearl clutching is unfounded at best and perhaps shows how out of touch you are with the realities of bedside nursing One nurse's 100% honest documentation is not going lead to some epiphany on management's part to start staffing the unit differently or otherwise improve the workflow. I got news for you, they already know the documentation is fudged and they want it that way.
Right. Which is why they check to see if, for example, neuro checks are charted q4h, but never check to see if anyone is actually doing them.
I know that if I miss a neuro check for whatever reason I'm not going to let that be a reason I get in trouble. I'm not sure it would make up for it if I wrote a note in that spot saying that I missed the check because I was coding a patient in bed 4.
I disagree with this, because If I hear lung sounds that are diminished or there are now fine crackles in the bases, or the heart rhythym is irregular, I call the doctor and I tell them. There have been time swhere my head to toe assessments have made a difference in my pt's care. Often, I have been told there are dressings on people's backs when there were not, and I find things that people "miss" or may not have even bothered to assess, so I cover my butt and I assess.
I have called and reported new crackles or new wheezing and been totally dismissed. Come in next shift and find the chest x-ray they did to appease me showed probable pneumonia. Hmmmm.
I've had patients say I'm the only one to check pedal pulses or edema and have had them say the other nurse "just squirts the medicine in there" for an IV push. Sometimes I don't want to know...
Right. Which is why they check to see if, for example, neuro checks are charted q4h, but never check to see if anyone is actually doing them.
I know that if I miss a neuro check for whatever reason I'm not going to let that be a reason I get in trouble. I'm not sure it would make up for it if I wrote a note in that spot saying that I missed the check because I was coding a patient in bed 4.
It wouldn't, and that's what out of touch people fail to understand.
But we're not talking about honest documentation, are we? Your choice to practice dishonestly. I don't/won't. And I do my best to protect my family members from care from people who practice dishonestly/unsafely. One nurse on this thread detailed how his/her father died because bowel sounds were charted as present when they weren't. Another nurse, who recently had surgery and was in the ICU, experienced no assessment of bowel sounds. Yet another nurse had to instruct her caregivers in the emergency room how to take care of her. And then there was the OP's friend. Just a few instances of how actions have consequences.
Not providing necessary care, and charting dishonestly, can have serious consequences for patients. It's easy to fall into the trap of thinking that "oh, it's just a small omission, or a small lie." Charting lies has consequences for the whole health care team, not just the patient. Quite possibly the nurses who didn't auscultate bowel sounds in the instances above didn't believe their actions could have serious consequences, if they ever found out about them. The patient dies, or is discharged, and it's their problem and their family's.
Fudging the time of a turn or oral care is not the same as failing to assess your patients. I would hope you're intelligent enough to grasp the distinction.
Fudging the time of a turn or oral care is not the same as failing to assess your patients. I would hope you're intelligent enough to grasp the distinction.
This thread is about failure to assess, and false documentation, and the consequences thereof.
I work as an OB mother/baby nurse with a patient load of 8-12 patients per 12 HR shift acuity level of acute to post op day 3. I do an assessment once a shift on all mom's and every 4 hours on babies. I don't chart it unless I do it. I precept a majority of our new employees and graduating nurses. I know other nurses who don't perform assessments and I don't trust taking report from them at the beginning of my shift for this reason. My conscious would not allow me to get away with not doing my job. Its to bad not everyone feels the same
I find it difficult to believe that it would be acceptable to not assess every patient in my care at the beginning of my shift. By that I mean a head to toe assessment, which really only takes about 5 minutes. I have worked on a very busy surgical floor where I had up to 7 patients in my care and am now in a CVICU/telemetry unit. How can I take care of a patient that I have not looked at or listened to? I do agree that not all body parts need to be assessed immediately. But just by talking to the patient I check neuro status. Then I need to at least listen to the lungs, heart, and abdomen, look at surgical sites, check IVs and IV sites. A patient's condition can change quickly and they need to be assessed at least once a shift. Let's not forget why we became nurses.
Specializes in Critical Care, Med-Surg, Psych, Geri, LTC, Tele,.
I wonder if assessments (or the lack thereof) are considered an issue in psych hospitals as well. People don't leave their medical problems at the door of the unit. As it happened, I was in decent physical shape except for my blood pressure and HR being too high, but not one nurse used a stethoscope on me the whole time I was inpatient.....just daily vital signs and weekly weights. However, one of the doctors conducted the most thorough physical exam I've had in YEARS. He checked DTRs, lungs, heart, bowels, edema, pulses, everything but a pelvic exam (which I'd had during the summer). Maybe that's the norm in mental health facilities, but I thought it was weird that no nursing assessments were performed.
Viva.... At my place of employment, a full physical is done by nursing staff on admission. There is no q shift requirement. The physical is supposed to be a head to toe (perrla, bowel sounds, lung sounds, etc) I would not be surprised to find out others do not do a complete physical, but chart that they do. But I have no way of confirming this. I hope they do.
VANurse2010
1,526 Posts
Unless you are going to start supporting her, your pearl clutching is unfounded at best and perhaps shows how out of touch you are with the realities of bedside nursing One nurse's 100% honest documentation is not going lead to some epiphany on management's part to start staffing the unit differently or otherwise improve the workflow. I got news for you, they already know the documentation is fudged and they want it that way.