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....