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6 Jan 2017 - General

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.)

Well, this is not new to me. During my volunteer days at public hospital, most nurses that i have encountered did their charting ahead of time most especially during peak season (in ward setting) . As you can imagine the scenario in public hospital. The ratio will run from 1:10 upto 1-30 ratio of nurse - patient. I know this should not be done especially if you are not able to see and assess the patient. Glad that you are able to confront him and gave him a red sign. It is up for him to do good ...
 (Total 102 words)
Marinelle Castro Yes exactly. I don't want to generalize that person being a dishonest staff just because of one single mistake. Anyhow what can we do in small things are always possible in bigger aspects. Really exhausting to catch up with too much paper works in the Philippines. Good thing other countries have this computer based type of documentation. I just hope this won't happen again. ...
 (Total 106 words)
Well, what I'm about to say next might not really count as advanced documentation, but it is something that happens in my ward everyday. at the end of every day, the nurses are supposed to put the next date, write a small patient summary and allocate the diet for the patient. In my ward, as soon as I finish the night ward round (around 8pm), they take all the patient tickets and do this documentation instead of waiting till 12 midnight. So when I need to document something that happens after...
 (Total 128 words)
Priscilla Mae Gobuyan It is good that you took notice about the behavior of your co-staff because advanced documentation is not acceptable. Paperworks can be really exhausting to do, but it is important to accomplish it with all honesty because it is a measure to ensure patient safety. I also hope that the nurse that you mentioned really monitors and examines as indicated, because people who are dishonest in doc...
 (Total 79 words)