3. Do you assume that if it’s not charted, it’s not done?
Many nurses claim that they’re taught “If it’s not charted, it’s not done,” but wait a second here! There’s something totally illogical about this “logic.” What if it has indeed been done? If an order for medication isn’t charted as having been carried out, but that order was given some time ago, something should twig in your mind that perhaps it was done but not charted. Giving a patient a medication when he or she might already have received it could potentially be fatal.
So scrap the illogical adage you’ve been taught, and ask questions if something isn’t charted but you suspect that it was likely done. Double-check with the patient, with the nurse you think may have taken care of it, with the pharmacy, with your supervisor if necessary…with anyone you need to.