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Documentation is a crucial part of our lives as medical practicioners. It has always been an ideal practice that what has been recorded is considered as done, and what is not is considered as not done.
I have this situation just a few days back. I was the outgoing nurse and it is our practice before heading home to check our charts for its completeness. While browsing the charts, I came across this advance entry of abdominal status monitoring of the incoming nurse who are doing their quick rounds with the patients. I was so disappointed to have seen that assessment covering his entire shift in advance without even seeing the patient. Plus knowing that the staff was a probationary is adding up injury to my mind that this is very unacceptable.
So I waited for him to finish the quick rounds and confronted him in the medication area, just the two of us. I told him why have he done such act which is considered as dishonesty. He just starred at me blankly, with a weird, flat looking tall guy. Due to my disappointment, I have confronted him in a sarcastic way which I am not sure if its right or not. Telling, "Sir, aren't you ashamed of putting an advance entry to your patients record? Is this the right way of documenting such act?" He further reasoned out to have defended himself which have added more to my disappointment. To cut the story short, I told him not to do this again as this is a ground for sending him to make an incidental report or even worst for being expelled from the institution as we have this one consequence for dishonesty, termination. For me this is the first time I have encountered with him and being considerate enough, I guess a verbal warning is acceptable. (I may be wrong for allowing this to pass by.)
Nurses and medical practiotioners are supposed to be delivering care to their patients as honest as they can at an optimum level. We are dealing with lives and not just merely playing around.
Do you have any thoughts for this scenario or have encountered a similar situation?
(The photo was the actual recording of the document which I took right after the incident. I was thinking to bring this to our headnurse but I guess verbal warning is acceptable at the moment.)