Need some advice about charting (RN)

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    My pt calls me into the room and requests a nebulizer treatment. I call Respiratory Therapy and the guy screams at me at the top of his lungs saying he will come when he can. My pt is getting really anxious. Pt complained saying that the Respiratory therapist walked in and out of the room without giving him his treatment. The Respiratory Therapist documented it as pt refused twice at 2200 & 0400. I called respiratory 4 times and no answer. I gave the nebulizer treatment myself and documented...

    Pt requested nebulizer treatment. Respiratory therapist ____ ____ notified. Pt complained "I never received my treatment, respiratory therapist fixed my bipap machine and walked out". See MAR. Nebulizer tx was administered by me, RN. Pt vital signs stable, pt currently sitting in bed with wife at beside. Continue to monitor.

    Should I have documented as I did? I was told by seasoned nurses to cover myself since the pt will be complaining to administration and I did administer the tx. Was there a better way to handle this?
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  3. 15 Comments so far...

  4. 2
    I'd keep it separated. The pt. wanted a neb, he hadn't had it, you gave it, end of story. Rt screams at you, you hang up on him and ask your supervisor to call RT as this is not your day to receive abuse.
    Altra and MaheaRN like this.
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    What you did is fine, particularly should a complaint/audit come up.

    Having said that, if RT was in back-to-back blues in the IC or ED, yeah, I can see getting ***** because Ms. Puffer, with COPD and a 200 year pack hx, who refused earlier, now wants her tx. OTOH, he/she RT should have apologized to you & explained, later on, were that the case.

    It helps to know the ancilliary staff, who's a slacker & who is not; it also helps to be aware of the pt's interactions with ancilliary, as much as possible. My wife (RT) used to have cystic teens who would refuse their tx, then an hour later, after they went outside for a cig, would have RT paged.
    Altra likes this.
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    i would have just left out names. Documentation isn't the place to point fingers at blame. If they want to know (as in the people who go over documentation or whoever reads that crap) then they will be able to figure it out by looking at the MAR and seeing it was refused by pt.
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    I hate mentioning names but it is our hospital policy. I have to list the name of the person notified whether it is a doc, pharmacist, respiratory therapist, even lab. I quoted what the pt had told me because he said I am going to report you and the respiratory therapist to administration (pt is a frequent flyer and well known at the hospital). The other pt in the room and the wife are witnesses. I didn't know what else to do. I work nights at a Level 1 trauma center and the supervisor was busy with an elopement. Maybe I should have left out what the pt stated...too late now can't change my documentation.
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    Always cover your own butt. I would have put “pt stated” not “complained”. You are only to put the facts, not your impression of them. You could have charted “pt stated (loudly or while crying or while clenching fists)……….Also I would have charted that you called rt how there was no answer 4x, and gave the neb. Would not have named names.

    I am wondering why bother calling the rt if it was charted as refuse – I can see if something was signed for and pt said did not get it?

    Its hard to know how to handle something while in the middle of it. You can’t change it now, I don’t think you handled it poorly.
  9. 1
    Makes me wonder if actually refused or RT just charted it that way to cover their butt for not doing it
    MaryAnn_RN likes this.
  10. 0
    This RT does this all the time. He charts pt refused (when he didn't even go into the room). It's funny cause nurses are the only ones that have to wear tracking devices at my facility. This particular RT hates waiting for pts if they have to use the bathroom or if he has to go the extra mile to make the pt comfortable. He gave the wrong patient tx once who was tachycardic & went into SVT. Many incident reports have been filed. Medication errors happen more often then we like...we're human but this guy is something else. I have never written him up because nothing serious has happened to anyone of my patients that he said refused treatment but never did. I'm trying to be a good nurse but feel like a terrible one. Work is stressful as it is. All this charting and legal crap is becoming way too much. I really stress about documentation. I tried my best with this patient to explain that the RT was busy, I gave him the tx but pt accused me of trying to cover for the RT. It was just a mess. I'm really nervous because I just started this job 3 months ago. I left a wonderful facilty because I was part-time and needed a full-time position and all I can say is that the grass is not always greener on the other side =(
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    you charted fine. I was told to state the facts. Not that he shouted or whatever but what happened which was what you wrote down.
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    I would have charted the facts and my nursing action only. I would have left out the entire statement of the patient complaint and taken it up with the RT and a direct nursing supervisor as a witness. If this were to somehow ever make it to a court of law, you would find yourself right in the middle of things. It would be patient's word vs RT's documentation and not yours.


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