I admitted a pt on my last shift who was ?CVA - for which the orders indicated that the pt was to be screened for dysphagia. I had never done one before but I've heard others talk about it and figured that I could do it just as well. But to be sure I ran the steps by one of my teammates - and I was correct....
so off I went to do the assessment - and the pt passed - so I went back to the computer to document it in meditech.
Somehow it didn't register it. I KNOW I did it - I know that I added the intervention myself and that I documented it. Not entirely sure that I put the intervention on the correct person but I know for sure that I did it.
Well now I'm getting in trouble saying that the documentation wasn't done and an incident report needs to be filled out - it's such BULLSHIT!!!!!!!
I'm seriously starting to hate this unit. Is it a huge deal whether it was done? The important bit was that it WAS done and was communicated to on-coming nurse who then communicated it to the next nurse.... hell if anyone was to actually ASK this pt if someone did this, they're cognitively in tact enough to say so I bet! But of course not, who would ever do anything so easy!
ARGGGGGGGGGGGGGGGGGG!!!!!!!!!!!!
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