Monday, August 21, 2017

Allergic to Documentation

One of my new duties is to audit certain aspects of charts.

There is little rhyme or reason to what I audit versus what I don't audit, but that is not surprising in this disorganized place.

Whatever I audit is a confused, contradictory mess with no hope of getting resolved.

Patient allergies, for example.

Patients are usually confused and evasive upon admission due to drugs (prescribed and street), their mental illness (usually schizophrenia), and their overwhelming desire to not be locked up on the psych ward (completely understandable).

A patient may provide one set of allergies to the nurse and a different set to the doctor.  Or claim an allergy to a medication that ruins their high or does not make them high.

As a result, my audits reveal a multitude of allergies, none written consistently throughout the chart, and none sourced.

Getting someone to address the matter is futile.  Yet my supervisor continues to ask, "So, you fixed the issue with the allergies on So-and-So, right?"

Well, no.  How can I?  People shrug their shoulders and either claim they have no idea why they wrote a certain allergy, or claim that "the pharmacy" or "the patient" told them that, so they have to write the allergy.  But not who gave them this information or when.

I can only hope I'm not blamed during the next inspection or survey.


Sunday, August 20, 2017

Hanging in There

I am still in my new position.

I do not do much.  The higher-ups don't seem to notice.  It's the other nurses and the orderlies- the people who still work the floor- who seem concerned.  Jealous might be a better word.

I'm afraid they will make trouble for me and cause me to lose this cushy spot.

I think I'm good at looking busy.  I spread papers out on my desk.  I don't openly use my phone, unlike people at the desks around me.

We shall see . . .