[New2ER]

I work in psychiatric ER the entire staff consists of myself (an RN) and a tech. My psychiatric experience includes working on the acute inpatient unit for 6 months before working down here fulltime. (I've been here for A year and a half).

We have an ER doctor who likes to order "assessments" by the psych ER staff for his patients in the medical ER. Keep in mind that our assessments are rudimentary and include psychosocial information and questions about S/I, H/I and A/V hallucinations. I DON'T have an advanced degree in psychology or license to diagnose these patients.

This physician will admit/discharge based on the information that is typed into the psychosocial on our computer system by the assessing RN. My problem is that he will then chart that he is discharging because the PSYCH RN did not find s/s of psychosis etc. No where in my charting do I make mention of discharging the patient, and what concerns me is that his charting appears to imply that he is discharging the patient based on my word RATHER THAN HIS OWN ASSESSMENT.

What exactly can/should I chart to protect myself against problems that might creep up due to HIS charting?

[My2Giants]

Sorry I have no advice since I am not familiar with psych ER.

I just wanted you to know that I read your post and hope that someone else will be able to assist you.

[PsychNurseWannaBe]

I don’t understand why he isn’t performing a medical assessment or referring the patient for a psych consult performed by a psychiatrist. I can somewhat understand if the patient admits to SI, HI or A/V hallucinations that the MD would then utilize your information gathered as he performs his own assessment… But a nursing assessment is not a medical one….so his lack of performing an assessment has me quite worried. You have a right to be worried that he is charting that you are doing something.

Even if the patient denies SI, HI or hallucinations, they may have a mental illness and it is the MD’s responsibility to get the patient treatment that they need.

How I would protect myself is to report it to your supervisor. I would also chart something like… “reported above findings to MD”. But if you don’t take a more proactive step… you could be setting yourself up for legal implications. But the bigger picture is the impact it has on patients who need treatment and are not getting it.