When I first started working on my unit, I was a little overwhelmed with five patients and everything that I had to do, however as the months have went on, I have become more comfortable with it. Nevertheless sometimes I still manage to get my charting switched up, which can lead to some funny incidents.
One night was particularly busy and it seemed that none of the patients wanted to sleep; instead it was if they had all plotted to ring the call bells all at the same time, for the entire night. This makes charting very difficult, because as soon as you sit down and chart one thing, you have to hop right back up to go see what the patients want and when you return your train of thought is pretty much ruined.
I had been trying to chart for the last couple hours and wasn’t accomplishing much, when finally the call bells grew quiet for a few minutes. I decided to take advantage of the quiet. I managed to completely finish charting on three of my patients. I then realized that I may have forgotten to mark on the charting that my patient had bilateral above the knee amputations.
I clicked on the patient’s name and discovered that I had mistakenly documented that the patient’s dosalis pedis as being 2+ palpated. Now that meant that I felt the patient’s feet pulses and they were normal…however the problem is this patient did not have feet due to the amputations. I fixed the charting and finished the rest of my other charting.
I then called report to another floor on one of my patients. This patient was moving to a private room due to cognitive behaviors and there was none available on the floor. I called report and then transferred the patient to his new room.
I returned to my floor and went into another patient’s room to do trach care. As I was doing trach care, the nurse I had given report called for me, my co-worker told her I would call back. When I was finished I called the other nurse back.
When she came to the phone she started to laugh. She said that she had a question. “Does this patient have feet?” I very quickly tried to figure out what in the world she was talking about. “Um...Of course, he has…” The nurse was laughing hysterically at this point and I joined in because I realized what she was talking about. I had accidentally charted the amputations on the wrong patient!!! It was quite funny because the nurse who had gotten my patient, said she had done her assessment and then went to chart and just happened to glance over my charting and had to go back to the room, just to make sure the patient had feet! I guess charting was not my forte that night!
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