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The next nurse got a complete report. The patient recovered. I completed the narrative about what occured the next day. this is allowed and perfectly legal. Yes doc is important I get that no need to flame or get distracted. Charting was on my review one month ago and it was stated on my review that my charting was not in deficit in any way. So for this to come out of the blue can easily be defended to HR and yes I do have protections. They cannot be blatantly unfair. I am pursuing those should it come to it. It is kinda funny but on the documentation of this issue mine is far superior to thetis. odd huh?
"The same day a patient at the end of shift had a problem. After fixing it I was an hour into OT so I told the oncoming nurse report and left."
Are you serious? You left without documenting?! How does your relief know what exactly you did to "fix" the problem? If this is truly your attitude toward documentation of patient care, it isn't difficult to figure out why your nurse manager is having issues with your charting or lack of it. You are a plaintiff's attorney's dream. Good luck to you in the future.
You are overreacting. see below. Actually it was my critical thinking which saved the pateint as the issue happened again the very next day.
That's an unproductive attitude to have, especially if you want to have a long career as a nurse. While it is true that a patient's immediate safety comes first, proper documentation about observations, symptoms, interventions, treatments and other such things is vitally important to your job. Not just for reimbursement purposes, but also as a way to shield yourself and your hospital from liability. You cannot brush off charting as unimportant or something that the next shift will do.
I thought I might get flamed on that one. "unproductive". Think it over though would you rather have a nurse concerned about your safety or protecting the corporate structure. In CC it comes down to that many times. If you opt for corporate I would question your sanity. Just sayin' its your butt not theirs and documentation completed the next day is perfectly legal for that very reason. JCAHO recognizes this as well. Improper labeling leads to far more poor outcomes than the flow sheet. That is the truth.
I thought I might get flamed on that one. "unproductive". Think it over though would you rather have a nurse concerned about your safety or protecting the corporate structure. In CC it comes down to that many times. If you opt for corporate I would question your sanity. Just sayin' its your butt not theirs and documentation completed the next day is perfectly legal for that very reason. JCAHO recognizes this as well. Improper labeling leads to far more poor outcomes than the flow sheet. That is the truth.
I'll side with you on this case, especially after being given further information. It is certainly completely fine to complete charting the next day. While it initially sounded like you were passing off all the charting to the next shift, after clarification it appears that isn't the case. And patient care and the immediate safety of the patient always comes first, especially in critical care. While the details aren't completely clear, there does seem to be some pressure from above that is directly affecting the unit managers.
Thank you for your response. I agree on the pressure. That is consistently what people cite. Ideally she responds to my email this week and gives feedback, I get the charting to where she wants it and it goes away. If not then it moves to another level. Her management skills are poor to none so hopefully by giving her some structure she responds. Since at this point it is only a charting issue that has been brought to me. If we must get into it so to speak HR will not be impressed with the review which cited good charting and now something else? As well I am suggesting reasonable steps to improve. If she declines those that will not be helpful.
I don't have a way to estimate if this is a grudge from above. Time will tell.
Thanks again for your valuable input. The administrative perspective here is very helpful from those of you who are in the know.
If this pencils out to be a grudge how should I approach the manager or HR? Any insight to that appreciated.
My impression of HR at the two hospitals I've worked at is that they'll collect your pee in a cup and will help you if your manager says something like, "Oh, well, you're black/Jewish/a woman/from Syria and I don't hire those kinds of people people." HR will defer to the manager in this situation, especially because it relates to "clinical activities."
Try to make your boss happy. Is there any logical reason that this woman would not like you? Believe it or not, most managers (at least the ones I've encountered) try to like all of their employees. So this is probably genuinely about the charting. Ask for some charting review, either from her, your clinical nurse specialist or the charge nurse and try to emulate them.
Alternatively, is there anyone else on the unit that's very trustworthy and might have some more insight into what's going on? Ask them, but only if you really trust them.
If they are asking other employees about you, then something is going on.
Either someone complained about your or someone 'in power' has an axe to grind. They see you as a problem for whatever reason and they are attempting to compile everything they can get on you. Now they are compiling as much as they can 'bad' about you via these nitpicky charts stuff or bad comments from coworkers. Who knows what else.
I have seen this occur to good employeess at corporations. It's often when one higher up gets word about some political thing that occurred and somehow one person gets blamed. Often the higher up doesn't get the whole story (just the complainer's version). Because it's political , they often don't get the other side of the story, EVER. They make wrong assumptions and sometimes a good employee is immediately stigmatized.
Sounds like this is occurring to you, OP.
Sorry to say, but it sounds like they are making a case to get rid of you. It's probably against your manager's wishes, since this manager recently gave you a good review.
I was a manager in such a position before and was almost forced by my upper management to make a great employee appear as a poor performer. I fought it and got mud all over my face by sticking up for a good employee.
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You left without documenting?! How does your relief know what exactly you did to "fix" the problem? If this is truly your attitude toward documentation of patient care, it isn't difficult to figure out why your nurse manager is having issues with your charting or lack of it. You are a plaintiff's attorney's dream. Good luck to you in the future.
