Can I ask another nurse to adjust a chart if I forget to chart something on my shift?

By | 2022-02-11T11:05:54-05:00 June 25th, 2009|0 Comments

Question:

Dear Donna,
I work the 3 p.m. to 11 p.m. shift in a long-term care facility. I have 44 residents to pass meds and give treatments to, along with calling doctors with lab values, etc. Many nights, I don’t get out until 12:30 a.m. to 1 a.m. I always manage to forget to chart something. What can I do when I forget to chart? Can I call the next shift nurse and tell her what to write for me and sign it the next day?

Edmar

Donna replies:

Dear Edmar,
Your post is troubling for many reasons. For starters, if you are so chronically overworked that you cannot adequately chart and get out so late, you need to sit down and speak with your immediate supervisor ASAP to get the situation resolved. Either you need some additional help with staying organized and getting your work done on time or perhaps other staff/resources are needed to help you.
Regularly “forgetting” to chart something is a very serious matter. Not only do you jeopardize your job and career, you put your patients at potential risk. The fact that you don’t know what to do if you do forget is also troublesome. Every facility has documentation policies in place that must be adhered to. Get those policies and read them and memorize them. The fact that you ask if you can call in and ask someone else to amend your charting – which is never acceptable and probably even illegal (though I am not an attorney) – shows a very serious lack of understanding of your fundamental responsibilities.
I don’t know what your level of experience or background is, but I sense you are in over your head. That means you are one shift away from making a mistake that could have serious consequences for you, one of your patients, and your employer. Let your supervisor know that you need help or look for another job where you will get the orientation and support that you need.

My best wishes,
Donna

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