Guest guest Posted June 30, 2006 Report Share Posted June 30, 2006 I personally would chart only from when I got there. Do your assessment and chart, pt has 20g iv with ns at 150cc/her in right antecubital or whatever, Arom'd per other nurse at .... with .... that way you are covering your own assessment and getting the pertinent information in the chart but not charting for a time frame when you weren't even there. I certainly wouldn't be comfortable doing that The Mays wrote: I have a question...sometimes when I come in to work at 7 instead of 5, my assigned patient (say..an induction) for the day has arrived and is in bed, IV started..sometimes AROMed...but there is rarely a note charted by whoever was in the room with her. The charge nurse said it is ok for me to go back and chart "IV started per Jane Doe, RN.." or whatever, and do a fetal assessment. I don't think that is correct if I was not even there yet, or clocked in yet. What do you guys think? I don't mind doing it but don't want to get in trouble for it one day. Oh..we computer chart.. sue Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 30, 2006 Report Share Posted June 30, 2006 I personally would chart only from when I got there. Do your assessment and chart, pt has 20g iv with ns at 150cc/her in right antecubital or whatever, Arom'd per other nurse at .... with .... that way you are covering your own assessment and getting the pertinent information in the chart but not charting for a time frame when you weren't even there. I certainly wouldn't be comfortable doing that The Mays wrote: I have a question...sometimes when I come in to work at 7 instead of 5, my assigned patient (say..an induction) for the day has arrived and is in bed, IV started..sometimes AROMed...but there is rarely a note charted by whoever was in the room with her. The charge nurse said it is ok for me to go back and chart "IV started per Jane Doe, RN.." or whatever, and do a fetal assessment. I don't think that is correct if I was not even there yet, or clocked in yet. What do you guys think? I don't mind doing it but don't want to get in trouble for it one day. Oh..we computer chart.. sue Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 30, 2006 Report Share Posted June 30, 2006 I usually do make an opening note similar to that.. " pt in bed with IV infusing...monitors on..blah blah... " but I really don't want to go back to before I was even there! Thank you! sue > I have a question...sometimes when I come in to work at 7 instead of 5, my assigned patient (say..an induction) for the day has arrived and is in bed, IV started..sometimes AROMed...but there is rarely a note charted by whoever was in the room with her. The charge nurse said it is ok for me to go back and chart " IV started per Jane Doe, RN.. " or whatever, and do a fetal assessment. I don't think that is correct if I was not even there yet, or clocked in yet. What do you guys think? I don't mind doing it but don't want to get in trouble for it one day. Oh..we computer chart.. > sue > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 30, 2006 Report Share Posted June 30, 2006 I usually do make an opening note similar to that.. " pt in bed with IV infusing...monitors on..blah blah... " but I really don't want to go back to before I was even there! Thank you! sue > I have a question...sometimes when I come in to work at 7 instead of 5, my assigned patient (say..an induction) for the day has arrived and is in bed, IV started..sometimes AROMed...but there is rarely a note charted by whoever was in the room with her. The charge nurse said it is ok for me to go back and chart " IV started per Jane Doe, RN.. " or whatever, and do a fetal assessment. I don't think that is correct if I was not even there yet, or clocked in yet. What do you guys think? I don't mind doing it but don't want to get in trouble for it one day. Oh..we computer chart.. > sue > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 30, 2006 Report Share Posted June 30, 2006 I don't mind charting what someone else did (IV started per.....or AROM per.....), but my assessment of the patient and fetus start when I arrive. Curious as to why the person you are relieving isn't charting what was done??? --- The Mays wrote: > I have a question...sometimes when I come in to work > at 7 instead of 5, my assigned patient (say..an > induction) for the day has arrived and is in bed, IV > started..sometimes AROMed...but there is rarely a > note charted by whoever was in the room with her. > The charge nurse said it is ok for me to go back and > chart " IV started per Jane Doe, RN.. " or whatever, > and do a fetal assessment. I don't think that is > correct if I was not even there yet, or clocked in > yet. What do you guys think? I don't mind doing it > but don't want to get in trouble for it one day. > Oh..we computer chart.. > sue Robbie __________________________________________________ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 30, 2006 Report Share Posted June 30, 2006 We are told that we cannot chart anything that happened when we weren't there. If that case goes to court, you're in trouble for making observations about something that happened when you are home in bed. Why can't that nurse chart what happened on her shift? You can only chart what happens when you are there, like someone said earlier your opening note (including who gave you report so they know who to go after if something wasn't done correctly on her shift. It sounds like they want you to take responsibility for things that happened while you were asleep. That would look bad in court. Deb ---- Sue May wrote: > I usually do make an opening note similar to that.. " pt in bed with IV > infusing...monitors on..blah blah... " but I really don't want to go > back to before I was even there! > Thank you! > > sue > > > > > > I have a question...sometimes when I come in to work at 7 > instead of 5, my assigned patient (say..an induction) for the day has > arrived and is in bed, IV started..sometimes AROMed...but there is > rarely a note charted by whoever was in the room with her. The charge > nurse said it is ok for me to go back and chart " IV started per Jane > Doe, RN.. " or whatever, and do a fetal assessment. I don't think that > is correct if I was not even there yet, or clocked in yet. What do > you guys think? I don't mind doing it but don't want to get in > trouble for it one day. Oh..we computer chart.. > > sue > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 30, 2006 Report Share Posted June 30, 2006 We are told that we cannot chart anything that happened when we weren't there. If that case goes to court, you're in trouble for making observations about something that happened when you are home in bed. Why can't that nurse chart what happened on her shift? You can only chart what happens when you are there, like someone said earlier your opening note (including who gave you report so they know who to go after if something wasn't done correctly on her shift. It sounds like they want you to take responsibility for things that happened while you were asleep. That would look bad in court. Deb ---- Sue May wrote: > I usually do make an opening note similar to that.. " pt in bed with IV > infusing...monitors on..blah blah... " but I really don't want to go > back to before I was even there! > Thank you! > > sue > > > > > > I have a question...sometimes when I come in to work at 7 > instead of 5, my assigned patient (say..an induction) for the day has > arrived and is in bed, IV started..sometimes AROMed...but there is > rarely a note charted by whoever was in the room with her. The charge > nurse said it is ok for me to go back and chart " IV started per Jane > Doe, RN.. " or whatever, and do a fetal assessment. I don't think that > is correct if I was not even there yet, or clocked in yet. What do > you guys think? I don't mind doing it but don't want to get in > trouble for it one day. Oh..we computer chart.. > > sue > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 30, 2006 Report Share Posted June 30, 2006 Sue , I have had this happen before (rarely). I do my best to just state the facts as they stand just as you said IV infusing FHR and membrane status. You really SHOULD make sure that you chart that AROM or whatever the RN responsible is written in the chart b'c if this chart ever gets called back if you don't chart when the AROM occurred and don't put who the nurse was you could really open a can of worms for yourself because you won't remember who it was and you will be the only one on the hook. It could be a quick note such as " pt continues to leak moderate amount of clear fluid after previous AROM at 0500 by Dr. assisted by Peggy Sue RN" This way you are not charting what you did not do. If this was a frequent occurrence I would raise holy heck about it and remind the nurse several times each day that this happened before she left. You could say "Peggy, how many lines do you think you'll need to finish up your charting" this way she knows there will be a blank for her to complete. But since you do computer charting ??? You could just keep reminding her (I am assuming it is one offender ???) and then if it continues you need to bring it to the nurse manager and remind her what an enormous liability this is for you and the other RN and the hospital (even the MD). Remind the other nurse that you are putting it in your notes ( make sure you never point fingers or blame in your nurses notes) and she would be glad if this case ever goes to court, if she has thorough and accurate notes upon which to rely. Hope this helps.... ________________________________________________________________________ Try Juno Platinum for Free! Then, only $9.95/month! Unlimited Internet Access with 1GB of Email Storage. Visit http://www.juno.com/value to sign up today! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 30, 2006 Report Share Posted June 30, 2006 Sue , I have had this happen before (rarely). I do my best to just state the facts as they stand just as you said IV infusing FHR and membrane status. You really SHOULD make sure that you chart that AROM or whatever the RN responsible is written in the chart b'c if this chart ever gets called back if you don't chart when the AROM occurred and don't put who the nurse was you could really open a can of worms for yourself because you won't remember who it was and you will be the only one on the hook. It could be a quick note such as " pt continues to leak moderate amount of clear fluid after previous AROM at 0500 by Dr. assisted by Peggy Sue RN" This way you are not charting what you did not do. If this was a frequent occurrence I would raise holy heck about it and remind the nurse several times each day that this happened before she left. You could say "Peggy, how many lines do you think you'll need to finish up your charting" this way she knows there will be a blank for her to complete. But since you do computer charting ??? You could just keep reminding her (I am assuming it is one offender ???) and then if it continues you need to bring it to the nurse manager and remind her what an enormous liability this is for you and the other RN and the hospital (even the MD). Remind the other nurse that you are putting it in your notes ( make sure you never point fingers or blame in your nurses notes) and she would be glad if this case ever goes to court, if she has thorough and accurate notes upon which to rely. Hope this helps.... ________________________________________________________________________ Try Juno Platinum for Free! Then, only $9.95/month! Unlimited Internet Access with 1GB of Email Storage. Visit http://www.juno.com/value to sign up today! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 19, 2006 Report Share Posted July 19, 2006 I love EASI inductions. (Extra Amnionic Saline Infusion)You don't have to check the patients so frequently and they seem much more comfortable than with Cervidil. When the bulb falls out, they're 4cm! :-) > It is not just one nurse. Some of us come in! at 5am, but on call or extra nurses (or those who choose i suppose)...come in at 7. I usually come in at 5. We are often short staffed from 5am to 7am and a few of us run around getting all the inductions in bed, IVs started and ready for the docs so they can start pit 30 minutes earlier than if we wait on the 7am nurses (note the bitterness) ANYWAY...when i do happen to come in at 7 extra I dont even know half the time who put the patient in bed when she arrived. I can sympathize, today from 6 to 7 I started 3 IVs, took care of 3 other easi caths ready for pit, and put 2 inductions in bed, gave nubain, antibiotics...all to get ready for the later nurses. HOWEVER I charted everything I did. > sue > > > Re: [OBnurses] Re: charting question > > > Sue , > I have had this happen before (rarely). I do my best to just state the facts as they stand just as you said IV infusing FHR and membrane status. You really SHOULD make sure that you chart that AROM or whatever the RN responsible is written in the chart b'c if this chart ever gets called back if you don't chart when the AROM! occurred and don't put who the ! nurse was you could really open a can of worms for yourself because you won't remember who it was and you will be the only one on the hook. It could be a quick note such as " pt continues to leak moderate amount of clear fluid after previous AROM at 0500 by Dr. assisted by Peggy Sue RN " This way you are not charting what you did not do. If this was a frequent occurrence I would raise holy heck about it and remind the nurse several times each day that this happened before she left. You could say " Peggy, how many lines do you think you'll need to finish up your charting! " this way she knows there will be a blank for her to complete. But since you do computer charting ??? You could just keep reminding her (I am assuming it is one offender ???) and then if it continues you need to bring it to the nurse manager and remind her what an enormous liability this is for you and the other RN and the hospital (even the MD). Remind the other nurse that you are putting it in your notes ( make sure you never point fingers or blame in your nurses notes) and she would be glad if this case ever goes to court, if she has thorough and accurate notes upon which to rely. Hope this helps.... > > > _____________________________________________________________________ ___ > Try Juno Platinum for Free! Then, only $9.95/month! > Unlimited Internet Access with 1GB of Email Storage. > Visit http://www.juno.com/value to sign up today! > > > > __________________________________________________ > Quote Link to comment Share on other sites More sharing options...
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