Monday, June 12, 2017


I went in to discharge a patient last night, and since she had been there a little over two hours I needed to check a set of discharge vitals. I opened a new cuff and p-ox and let them run while I was going over the paperwork, then wrote down the vitals and waved her off to the exit. Back at my computer to chart all the discharge paperwork, I noticed that the blood pressure and heart rate I had just taken were the exact same as the triage set. Does anyone else ever get that weird feeling when this happens that if your chart gets audited, whoever is reading over it will scoff and be like "chyeah, obviously they didn't check discharge vitals! No one has a repeat BP of 143/68 and HR of 71! I'm definitely going to call them in for a meeting."

I then had a moment of questioning if I should change it by just a single number, to 142/68 or something, just enough to make it different and clearly a new set of vitals. Or even to chart the correct identical BP/HR, but free text a note that yes, they are in fact a new set. Which then led to me feeling horribly guilty for even thinking about falsifying data, but also wondering if I'm just a crazy person simply for having this series of thoughts.

Paranoia over chart auditing is such a weird thing.

And then I remembered that everyone, everywhere, always charts 16 as the RR (edit: in the stable, non-respiratory or neuro patients. I'm not that shitty of a nurse; geeze, guys!) and then I felt better about myself.

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