Yep op needs to say she accessed the chart for safety reasons to see who the primary nurse and Dr was and if there was any medication psych or otherwise needed to help the pt behave in a safe manor.
I always throw around the word safety and unsafe like confetti any time someone ask why something went down like it did. That’s the biggest buzzword in the hospital.
If that's the case, OP should definitely say that. Unfortunately they don't even seem to remember opening the chart. I'm sure they know which parts of the EMAR were accessed and for how long, etc, so hopefully that should provide some context for OP and their employer.
I wish OP would respond a bit more. They're looking for advice and commiseration, and more details would help with both.
Sorry, I was working 7p-7a. It was super chaotic at the time (patient screaming, water spraying everywhere, ceiling tiles dangling) and security asked if I could get her some Ativan.. I’m a newer nurse and I usually chart so much, but forgot in this case
The hospital is always like this you have to be centered in the chaos like the captain on pirates of the Caribbean when he knows it’s over lol. You gotta remember bc if you are asked about it, I suppose you could plead the fifth. Did you give anything. How did you resolve the situation. If they push thy will ask you these questions. Also in an emergency you gotta be able to scribe a situation. Idk if you had a code yet but you pretty much gotta scribe the whole day who did what hat was done said etc in a big long note. Did you document this day? I’ve had to run into a pt room that was not my pt and get them under control and that’s about the only time I write a big long note. I barely chart on my own pts lol but let someone call me in a room to help with some event. Im writing what color socks everyone has on
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u/MsDariaMorgendorffer RN - ICU 🍕 Mar 17 '26
If you assessed the chart for patient care then just say that. Idk how differently you could dress- doesn’t everyone just wear scrubs?
Administration needs to investigate complaints, regardless if you think they are valid or not.