not documented, not done. what does this mean?

[kmahoneyrn]

i am looking for a respnce to the statment 'Not documented, not done." Was this taught to you in nuring school, in clinical practice or it is a part of your policy manual, or all three?

[RNIAM, BSN, RN]

What is sad ,is that it has come to this to begin with:o

[MQ Edna]

Years ago, I heard of a physician who lost a legal case in which a child was DX'd with cretinism and the MD was found to have missed it. WELL--he saw the child once, when the kid had a bad cold and an ear infection. The parents had never taken the child anywhere for well-baby care (no immunizations, etc), did bring him back once for a recheck on the ear by the nurse, and were never seen again. Until they sued. Unfortunately neither the doctor or the nurse had documented on the chart that the youngster hadn't ever had any medical care, that the parents were advised to follow up with immunizations, etc. So "it wasn't done" and the parents were awarded half a million dollars

[P_RN, ADN, RN]

C Y A

[jevans]

I've just spent the last 4 hours auditing documentation:o

Now, the staff on my unit are excellent and their documentation is good. BUT today I have just had to ask one of my staff why she did not check a blood glucose on a diabetic patient who fell. Her answer was - she did HOWEVER it was not documented SO it appears as if she did not follow through. It's sad cos I know that she probably did!

j:kiss

[deespoohbear]

Good documentation can save your backside bigtime. Not only in a court of laws, but with the doctors. I had an elderly lady one evening going into obvious CHF. She was A & O X3. I put O2 on her, elevated the head of the bed and called the on-call family doc. Told him of all the signs and symptoms. He asked, does the patient want agressive tx? So, I went in and talked with this pt. She said no aggressive tx. Just wanted kept comfortable and let nature take its course. I called her daughter who happened to be an RN and told her that her Mom appeared to be in CHF. Told her that her Mom requested no heroics, comfort measures. Pt did not want transferred to larger facility, or even our ICU. Daughter okay with that. Call family MD back. DNR order received along with MS and Lasix. Meds helped ease this lady's discomfort. Family arrived in the night. Next morning her regular doc has her transferred to ICU and cardiology consult. Cardiologist mad as a wet hen because pt "had been neglected all night." The cardiologist reported me to my supervisor. Supervisor checks the chart and tells the MD to read the charting. Never heard a thing from the doc. Patient dies 4 days later in ICU with a central line, dopamine and dobutrex hanging and probably a $40,000 bill that she and her family didn't want.

As someone said earlier:

CYA CYA CYA CYA!!!

[mother/babyRN, RN]

Here is an example even though I am usually one to document everything, even as simple as stating that I check on a sleeping patient every hour (or more if indicated) and write that their respirations are deep and even. Had a patient go for a surprise emergency crash c/s. Had her in knee chest actually holding the fetal heart monitor on her abdomen while the other nurse was setting up the OR and the doc was making all the phone calls. Later, when reviewing documentation. When all was said and done everyone was thankfully ok, and the family was very happy with the nursing and doc care and the outcome . Our bosses wanted us out of there so not as to pay us any overtime BUT, although we have the fetal strip, I did not go back and put what we did when the HR fell ( I was on my knees at the time). so, although it does say knee chest, no mention was made of the actual heart rate, all we did before knee chest, documentation of the failing heart rate (even though you can see it on the strip_, before "decision for c/s" was included in the notes. It looks like we called the doc, put her in knee chest and then he made a dec for a c/s. Thats a tough lesson because if we ever went to court they could theoretically say we didn't do much when in reality we were doing all we could.

Now a days people think filling out a flow sheet will keep you safe with regard to documentation but if you have a converstation with a patient, or spend a long time teaching or consoling them, write exactly what you did when you did it.

Charting by exception may save time and paper work but it will not save you in court...

[nursegoodguy]

OBNURSEHEATHER really had a GREAT point! Doctors always say, "Oh I had no idea???" When you document it be sure you also notify the proper people of your findings... such as the doc & family member...

[fiestynurse]

Yes, they do say in nursing if it is "not documented, then it was not done." And I agree that good documentation will save your butt in a malpractice suit. However, nursing documentation is only one piece of evidence to prove that something was done or not done and other factors can figure in. Such as, routine care that is done on all patients doesn't necessarily have to be documented. Also, you and witnesses can testify in court to help prove that you did or didn't do something.

[Tiiki]

"Not documented, not done," is our mantra. We use integrated progress notes, which mean that all the documentation on a patient is in one place, so you may chart after the RT, or after the MD, etc. That cuts down on looking for individual notes. It also makes the MD more responsible in that he/she can no longer say.."was such and such done." Our charting is supposed to be by exception, but during nights, it's an hourly thing, even if you write, "pt sleeping soundly, IV insitu & running well, no signs of distress." It shows you did your rounds, you are aware of goings on. I had on MD actually correct my charting. It was a horrendous day, and I charted on one pt the following.."pt in pain, breakthru given." I figured since there was only one narcotic break thru PRN med I was clear. NOPE! The MD wrote in RED!!! "WHAT MED? WHAT DOSE?" That taught me to be very specific about everything, from am to hs care. I have found it also covers your ass if a family member or patient for that matter starts complaining of the quality of care given.

Cheers!

Jo-Anne :)

[Chiron]

I was taught to document as if your notes were going to be read by a prosecuting attorney in a court of law.

the facility I work in uses a standarized computer template for repetitious documentation that speeds things up by just clicking with the mouse. Nurses are also required to write a FOCUS note on each patient.

[KaraLea, LVN]

Originally posted by Chiron

I was taught to document as if your notes were going to be read by a prosecuting attorney in a court of law.

Not only that, but document as if your notes were going to be read by a prosecuting attorney in a court of law in a year or two...

[OrthoNutter]

I keep telling the doctors this. They must think I am a mind reader because they're always asking me, why didn't pt X get a once off dose of Gentamicin? I'll go fetch the med chart and file chart and ask them to point out where exactly they ordered this. Of course, there's never an order but they'll say "oh but I was saying to Nurse Y that I wanted to give Gent to pt X". Out comes the old....

If it's not charted, it doesn't get done.