Documenting injection the MD gave

  1. Is this a wise thing to do? I work for an urgent care, we have Dr/PA/NPs rotating constantly, hardly work with one more than a few times. An MD gave an injection he ordered and wanted me to document it. I didn't see him drawing it up or administering it so I wasn't at all comfortable signing off on it and I declined to do so. Of course the MD was miffed but you would be shocked at the amount of providers who cannot correctly give an injection and I didn't want my name on that. He said I could type in the comments he administered it but if a problem were to arise, its his word vs mine. Was I in the wrong? I would never do it for another nurse but was unsure if same goes for the providers...
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  2. 41 Comments

  3. by   elkpark
    I would not be willing to document that the injection was given unless I saw the physician administer it, and I would not be willing to document what the injection was unless I drew up the medication myself or watched the physician do so (verified the vial and the amount in the syringe). And I wouldn't be thrilled about doing either of those things. Otherwise, no way.
  4. by   macawake
    Quote from SaltySarcasticSally
    An MD gave an injection he ordered and wanted me to document it. I didn't see him drawing it up or administering it so I wasn't at all comfortable signing off on it and I declined to do so.
    While I both draw up and administer the majority of meds that I give myself, sometimes a physician I'm working a case with (anesthesia) will draw/adminster the med. Since I'm right there seeing what s/he's doing and also knowing what meds I had stocked on my cart, I'm comfortable signing off if the physician doesn't (which they actually will most of the time). But I would never do that under the circumstances you described.

    Something similar actually happened to me when I worked in the ER when I was a "newish" nurse. A not too polite physician told me to chart some med or other as adminstered to patient A. Since I hadn't even been in the room, I declined. He then tried to order me to do it (throwing in a mini-tantrum to boot). (No, thank you )

    Being that I'm a bit of a smart***, I asked him at that point if it wouldn't look unprofessional if the chart read "unknown medication administered to patient A by physician B at unknown dose, adminstered at unknown time, at unknown route/site, using unknown technique", (Signed, Nurse Snark) and that it would be better that he who was privy to all the details, charted it. (I wouldn't have responded to in such a rude manner, if this particular physician hadn't had a previous history of being quite obnoxious). And strangely enough, we got along just fine after that incident. Oh, well... People can be funny sometimes.
  5. by   elkpark
    Quote from macawake
    Being that I'm a bit of a smart***, I asked him at that point if it wouldn't look unprofessional if the chart read "unknown medication administered to patient A by physician B at unknown dose, adminstered at unknown time, at unknown route/site, using unknown technique", (Signed, Nurse Snark) and that it would be better that he who was privy to all the details, charted it. (I wouldn't have responded to in such a rude manner, if this particular physician hadn't had a previous history of being quite obnoxious). And strangely enough, we got along just fine after that incident. Oh, well... People can be funny sometimes.
    I've found more than once over the years that the physicians (and others) who are most overbearing and unreasonable often have respect for the people who stand up to them and call them on their bad behavior.
  6. by   Purple_roses
    If you didn't document it, you didn't do it right? I suppose the reverse should be true too: if you didn't do it, don't document it!

    Just as long as the MD really does document it so that the patient doesn't get a double dose.
  7. by   soutthpaw
    Would it be inappropriate to make a nursing note along the lines of
    X MD ordered me to chart his administration of Y med to patient. Informed MD I cannot do that as it's a violation of hospital policy and the state nurse practice act.
  8. by   Spidey's mom
    Quote from elkpark
    I've found more than once over the years that the physicians (and others) who are most overbearing and unreasonable often have respect for the people who stand up to them and call them on their bad behavior.
    That's my experience as well . . . for the most part.

    I wouldn't have signed OP. You did the right thing.
  9. by   Double-Helix
    Quote from soutthpaw
    Would it be inappropriate to make a nursing note along the lines of
    X MD ordered me to chart his administration of Y med to patient. Informed MD I cannot do that as it's a violation of hospital policy and the state nurse practice act.
    Yes, it would be inappropriate. A note like that belongs in an incident report, not a patient’s medical record.
  10. by   Ruby Vee
    Interestingly, since I'm usually a stickler for the rules, I might have documented it as given. Our software has provisions for documented "given by other" and a spot for notes describing the circumstances under which you're documenting for someone else. If you drew it up, you can attest to the drug and dose but if they draw it up themselves, you can say something like "Fentanyl 250 mcg. vial provided to Dr. Bowel for colonoscopy -- Dr. Bowel states that 200 mcg was given by him in divided IV doses during the procedure; 1cc (50 mcg) wasted with Dr. Colon." The software then flags Dr. Bowel and Dr. Colon so that they can sign off on giving and wasting the Fentanyl. If they don't co-sign within 24 hours, the flags become increasingly strident until they DO sign it. The narcotic count is correct since you've documented that you signed out a 250 mcg. vial for the procedure and that you've given it to Dr. Bowel to administer. If they think ahead and waste it with you, or give you the leftover medication to waste with your charge, that's great. But they often just throw it in the needle box, and that way they're responsible for signing the waste.

    There's also a way to document that "Dilantin 100 mg. IV ordered and administered by Dr. Seizure." It's an actual order and when it populates the MAR, it's already charted as given.

    Back in the days of paper charting, it was far easier to just write that, but some computerized charting does provide a work around.
  11. by   ArtClassRN
    Our EMR has a "Provider administered" option. If that isn't enough you can always put in a progress note about how you were given a verbal notification about the administration but did not witness it blah blah blah.

    This is really not an issue in the environment that I work in.
  12. by   Workitinurfava
    Do you trust him with your life, should something be questioned?
  13. by   soutthpaw
    Quote from Double-Helix
    Yes, it would be inappropriate. A note like that belongs in an incident report, not a patient’s medical record.
    Thank you, Only being a student currently I was unsure if something like that needed any documentation and where one would put it... I will keep this in mind should the need arise in the future...
  14. by   BrnEyedGirl
    Just to play devil's advocate here,...I am a new NP (1 yr) and work in ED. Recently during my shift, we were very busy with several critical patients in the department. The nurses were overwhelmed with trying to get two patients ready for the cath lab, one elderly DNR patient on CPAP actively dying, as well as two septic infants that needed to be flown out. While I am currently in the role of NP, I am a very experienced ED RN and completely capable of helping. We had 4 hall bed patients that needed lines, labs, fluids and meds. I started the IV's, hung the fluids and gave nausea and pain meds. Then I realized that our EMR does not give me an option to mark these things as completed or even a place to chart details of my lines! I did place a free text note in each chart of the tasks that I had personally completed, but the nursing staff had to "officially" chart completion of the orders. I can't see the "nurses" side of the charting as a provider, I had no idea! It was taken care of, and everyone was happy for the assistance, but I'm not really sure how the EMR required them to mark these orders as complete.

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