If It's Not Written..
I had my final OB clinical yesterday. The early morning before I arrived there was a fetal demise. I am not going to get into to many (HIPAA hippo) details, but the situation is not good for anyone. The chart is a mess, and the hospital and its players may face some stiff penalties.
In front of my clinical instructor, the NM states to another,"We may have to call those involved back in to add late entries to the chart....'fix things up.'" Yadyada. My clinical instructor is the sweetest, calmest lady ever. It seems a lot to get her rattled; when she says "I am upset..." then my reaction in the same situation would be..."Whaa the nfouivht8gny0475g[******pivjhdas!!! (at the top of my volume threshold) But, for her, it was in post conference for us students:
(calm, quiet voice) "OK there is something I want to make clear that you never. never. never. never. never. Want to do. You never change the chart after the fact. You chart very detailed at the beginning, and then there is no mistake about events and how they occurred. I have always been chastised for writing too much by other nurses, but if you don't write it down, it never happened. The chart, once again, is a legal document." She also added to stay as clear as we can from hospital/job politics and the 'mob mentality' and bickering by focusing on our patients. Such wise advice.
There was more, but I don't want to share many details. I had a sick stomach with this all day. Th nurse I shadowed (the followup nurse taking care of mom after the fact) had a sick stomach with this as well. So, we learned from others mistakes and "what NOT to do" on this day, rather than what TO do....
In front of my clinical instructor, the NM states to another,"We may have to call those involved back in to add late entries to the chart....'fix things up.'" Yadyada. My clinical instructor is the sweetest, calmest lady ever. It seems a lot to get her rattled; when she says "I am upset..." then my reaction in the same situation would be..."Whaa the nfouivht8gny0475g[******pivjhdas!!! (at the top of my volume threshold) But, for her, it was in post conference for us students:
(calm, quiet voice) "OK there is something I want to make clear that you never. never. never. never. never. Want to do. You never change the chart after the fact. You chart very detailed at the beginning, and then there is no mistake about events and how they occurred. I have always been chastised for writing too much by other nurses, but if you don't write it down, it never happened. The chart, once again, is a legal document." She also added to stay as clear as we can from hospital/job politics and the 'mob mentality' and bickering by focusing on our patients. Such wise advice.
There was more, but I don't want to share many details. I had a sick stomach with this all day. Th nurse I shadowed (the followup nurse taking care of mom after the fact) had a sick stomach with this as well. So, we learned from others mistakes and "what NOT to do" on this day, rather than what TO do....
posted by kimberly at 6:55 AM
2 Comments:
Amazingly, we have been instructed to not write so much when charting, because it could come back to bite you in the butt.
I tend to want to write everything I did for the patient, (gave meds, I/O, dressing changes, wound assessments, etc.) My instructor says if it is documented somewhere else (like the litte tick-boxes they use in one of the facilities, or on the MAR) not to write it. So my notes are always so lame.
"Patient received in bed resting comfortably. No visible signs of distress."
And that gets an A. :(
W. :)
Oh, man. I'm so sorry you had a terrible day. On quite a few levels.
Charting is a tough one for me, as well. I feel like I want to put more detail in for fear of leaving something important out. And then my instructors get to crossing out left and right, and my charting is reduced to a paragraph.
Your scenario is one I dread becoming reality in my life. Wendy is right. "A" material is scary.
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