RN's, how do you document findings which are out of your scope?

  1. When calling docs about a new finding that's clearly outside of one's scope (in this case, primary RN finding bowel loops very high in the chest on a pcxr on a post-sternotomy pt due to a trauma) how would you effectively document the reason for the call? Not asking for what to say to the doc, that's covered . I'd like the phrasing to withstand reasonable medical-legal scrutiny.
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    About Wile E Coyote, LPN, RN

    Joined: Jan '07; Posts: 528; Likes: 1,519


  3. by   BellaInBlueScrubsRN
    CXR results call to Dr. So and So.
    I would't feel the need to chart anything about the actual results.
  4. by   meandragonbrett
    Reading a PCXR result is not outside of your scope of practice. Interpreting the film would be outside your scope of practice.

    You can simply document "John Doe MD notified of most recent PCXR results r/t bowel loops noted in chest. No orders received." etc.
  5. by   elkpark
    It's never out of our scope of practice to describe what we observe, it's drawing conclusions and making diagnoses that can be a problem.

    However, I agree that simply documenting that you called the MD regarding the CXR and any outcome of that call is sufficient, without going into details about the CXR itself. From a "medical-legal scrutiny" point of view, we can never go wrong calling the physician about something -- it's not calling the physician that could get someone into trouble.
  6. by   BellaInBlueScrubsRN
    A dictation of the CXR result would be on the permanent chart record with time/date anyway. That would cover you legally without having to chart the findings yourself. Just chart that you called.

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