Sunday, February 21, 2010

Stop making trouble

I found a fresh scab on a resident. Put it in the nursing notes and did a brief incident report.

Told the incoming day shift nurse about it. She retorted, "That's been there. It's clearly documented upon admission."

Well, the scab was not documented at any time since the resident was admitted three weeks ago. I checked before writing the incident report. There is really no need for the day nurse to be concerned; it's not as if she would be blamed. I usually write one or two incident reports per shift. The Director of Nursing wants it that way.

The next day, I checked the resident's chart, and sure enough, the nurse had scribbled in "scab" on the diagram of the body at admission. Another nurse did the admission, but it didn't even faze her to attempt to conform to his handwriting. The scab is not mentioned in the admitting nursing note, but she didn't scribble in "scab on left trunk" in a little gap.

And yes, she will get away with it. Nobody will even tell her to not alter the medical records. The thing that really gets me is that there was absolutely no need for her to go back and doctor the record. It's as if she just likes to prove that I go around making trouble where none exists.

When the Director of Nursing hears of this, which the night supervisor will tell him, he'll call it a "cat fight." He will see no problem with altering the record, but he will see a problem with my trying to create trouble for others by pretending that an old wound was new. As if I have time to write fake incident reports.

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