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Oct 23, 2002, 01:28 PM
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ON MY SHIFT I FOUND A PATIENT DOWN AT SIDE OF BED. DIED OF SUBDERMAL HEMATOMA THREE DAYS LATER. THE RN ON SHIFT MADE ALL THE NOTATIONS REGARDING THE INCIDEN, EVEN THOUGH NOT THE ONE WHO FOUND PATIENT. SHOULD I HAVE MADE SOME DOCUMENTATIONS REGARDING FINDING THE PATIENT?
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Oct 23, 2002, 02:12 PM
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at my facility, there are incident/risk reports. when it comes to a patient who has fallen, the person who witnessed the fall or found the patient on the floor is supposed to fill it out. if you facility doesn't have a form like this then i would think that the primary nurse documenting the event would be okay. i think it depends on your facility's protocol.
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Oct 23, 2002, 02:24 PM
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IN THE MEDICAL RECORDS, IT LOOKS LIKE I DID NOTHING AFTER FINDING THE PATIENT. THE RN DOCS "FOUND DOWN" ONLY . SHOULDN'T IT BE NOTED BY WHO?
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Oct 23, 2002, 02:28 PM
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i am not a legal expertise, so i don't want to steer you in any particular direction. if i read a nurse's notes and it said "found down." i would assume that the nurse who wrote it found the patient down. but that is just me. i don't know what to tell you....
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Oct 23, 2002, 02:35 PM
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NO INCIDENT REPORT WAS FILLED OUT! THEY ARE LOOKING AT ME FOR COVERING UP. THE RN DOESNT "REMEMBER "WHO FOUND THE PATIENT
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Oct 23, 2002, 03:25 PM
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Why don't you fill out a incident report now,list the date and time you found the patient, who you notified, any tests or treatment the patient recieved.
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Oct 23, 2002, 03:50 PM
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thanks, i will do that, but it still looks bad. i guess i should have made of doc of my own.
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Oct 23, 2002, 03:58 PM
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Wow an incident report seems like it should be recorded by the one who found it. You can always fill it out and date it in the body with the date and time you found them and an explanation why it was done late. Better late than never to CYB. We always had to document falls on incident reports.
renerian
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Oct 23, 2002, 03:59 PM
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I meant to say found them.......not it.........oops typo. Good luck to you in resolving this situation.
renerian
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Oct 23, 2002, 04:07 PM
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since i didn't fill out an incident report myself, can i find out IF and WHO did, by any other MEANS than asking the shift nurse,
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