Documentation

  1. Where I work, there are some MD's who seem to take quite a long time to call back when paged. When it comes to documenting, let me know what you think of this:


    1800
    Pt. reports increase in pain to abdomen. Rates pain 8/10. No nausea or vomiting. Call out to Dr. X. to update on condition.

    1845
    Page number two to Dr. X. regarding Pts. pain level. Will continue to monitor closely.

    1930
    Page 3 to Dr. X.

    2000
    No reply from Dr. X. Dr. Y calling, stating can't get Dr. X. on pager, update given regarding patients status. New orders noted.

    Just curious as to what my peers think on this kind of documenting. It appears to cover me. I am wondering because I came to work the next day and the doctor crossed out the rest of the page and crossed out the back of the page and started his note on a new piece of paper. Perhaps making it easier to make my notes "disappear"... ?? Should I have documented differently. Haven't heard anything from my bosses... JOHN

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  2. 5 Comments

  3. by   Tweety
    Whether the doc is trying to make your notes disappear they are in there. I always document times and call backs, and number of times called when a response isn't timely. You did a good job.

    The only thing I can offer is her pain isn't very descriptive, but it's probably documented somewhere else and your just noted an increase in pain. Location, intensity, and duration should be noted.
  4. by   angelbear
    I too always doc. who was called why they were called time they were called and if and when I get a response and what the response is. If he is in fact trying to make your documentation disappear that is illegal and he could get in big trouble. Even if your documentation was inappropriate which it wasnt they still cant just make it disappear. Ya done good.
  5. by   A/A/OX3
    To error is human to forgive is devine, unless something happens to the patient when you were calling him a gazillion times and he never returned the page. In that case, he never got the call and nurse CYA is sadly mistaken.

    One of the hospitals where I worked some time ago used to log the calls as they were made to the doctors. It was a record they could not dispute. I think all hospitals should use this system.

    However, I have to say, make sure you know who is on call for their service. I have called the wrong doc on more than one occassion.... duh-h-h-h-h-h!!
  6. by   P_RN
    Perhaps also an occurrence report? Doc can't touch that.
  7. by   Tweety
    Originally posted by A/A/OX3
    To error is human to forgive is devine, unless something happens to the patient when you were calling him a gazillion times and he never returned the page. In that case, he never got the call and nurse CYA is sadly mistaken.

    One of the hospitals where I worked some time ago used to log the calls as they were made to the doctors. It was a record they could not dispute. I think all hospitals should use this system.

    However, I have to say, make sure you know who is on call for their service. I have called the wrong doc on more than one occassion.... duh-h-h-h-h-h!!
    Oh I hate when I call the wrong doc in the middle of the night. Happened to me more than once. Ouch.

    On long and no call backs, I've called the answering service to get the times, and they too keep a very accurate record of the times called.

    The incident report isn't a bad idea either.

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