I'm a new grad working on my own for almost a month now, starting in ICU at a hospital where the acuity of the patients is rather low, so I consider it a SICU. I had a pt with a history of cvs with right sided weakness. She was obese and refused her scd stockings. I knew this woman was a huge risk for clots, so I educated her and charted the education and her refusal. To cover my butt, I called her attending md to let her know, and asked if sag wanted to try an alternative DVT prophylaxis. She stated ..this pt was on a Helprin protocol right? I said yes but it was stopped. She said ok give her 30mg lovenox sq daily. I wrote it down on the chart and got the med from pharmacy. Gave teaching to pt on lovenox and administered med. I documented a MD notified for the refusal and that new orders were received. I get a call a week and a half later from my unit manager saying that the dr refused to sign the order because the pt has HIT. They sent a HIT test out during the shift prior to minr, but I hadn't seen the results and not sure if they were even back yet. The unit manager asked if I was sure it was tht dr I spoke to. I said yes, and in the chance that it wasn't, it had to be someone who was covering for that dr since they were clearly aware of who the pt was, even stating to they knew she was previously on a Heprin protocol. The mgr told me I need to be sure, and asked if I'm trying to say the dr was lyng? I was shocked!! I told her to check the phone records and see if that particular MD called on the date and time tht I charted her telephone order. She said she can check to see who was on call tht day. I JUST got my license a few months ago, and I'm shaking at the thought of loosing it over a matter of her word against mine. When r they going to start recording every phone call so ths doesn't happen. I am so angry and I wanted to know what I could do to prevent this from happening again, if anything.
