Long, long ago, I was doing a consult for the Medicine service, and I was trying to find out blood sugars on a diabetic patient. They were usually listed with the patient's medications, but I looked through the whole chart and they were nowhere to be found. Finally, I located the patient's nurse. "Where are the blood sugars recorded?" I asked her.
"They're in the chart," she told me.
I checked again. "I don't see them. I see blood sugars from yesterday, but nothing from today. Did you check them today?"
"Yes, of course," she said.
"Where are they written down?"
"I didn't write them down," she said, as if the idea were preposterous. She tapped her head: "They're up here."
Me (baffled again): "Uh... can I... see them?"
Good gravy. I hope she won't be my nurse one day.ReplyDelete
Wow. Thats ballsy, we have to charge for those and chart them... I'd almost say she didn't do them. I'd have checked the meter or something. Why would she take the time to do it and then not chart it.ReplyDelete
My Mom, the Old RN is going to spit. I don't know how many times I have heard in how many professions, "If it is not written down, it did not happen."ReplyDelete
At least she didn't make them up and write them down...we've all seen a few extra sets of suspiciously normal vital signs on a patient who was actually cold and dead.ReplyDelete
While I may not have gotten a chance to chart on the computer system, not enough computers at times, I always have my "cheat sheet" where I have important stuff like that noted so I don't forget it before I get to the computer and have more than once showed that to the doc!ReplyDelete
I've had plenty of nurses do the same thing, on a napkin or towel or whatever when I asked for vitals/sugars/etc. I think it's fantastic!Delete
The blood sugars on our unit automatically go to the computer when we dock the glucometer. It's perfect!ReplyDelete
Had you asked me, I might well have checked someplace on my scrubs, or on my arm, or the patient's sheet, or something else that will stay put and not be accidentally tossed, until I get to chart it. TriciaReplyDelete