Permanent documentation... "Please advise"? - page 3
by BiohazardBetty 4,489 Views | 27 Comments
My facility has recently changed to electronic charting from paper charting... Consequently, there's no easy way to send a message to a doctor for advice without making it a permanent part of the chart in what's called an "event... Read More
- 0Nov 24, '12 by Susie2310Quote from mappersThe OP asked in his/her last sentence "How would you communicate this info & ask for advice?" Hence the replies.I think it is interesting that people are missing the point that the OP was discussing sending a message for the MD electronically in their electronic medical record as opposed to leaving a post-it note or something similar on a paper medical record. She is not talking about charting or her nursing note. Separate issues. People keep responding to what she charted, when she didn't tell us what she charted.
Her concern is that the electronic message becomes a permanent part of the record, as opposed to a post-it, which does not. This, ultimately, is a good thing for the nurse since she now has proof that she did notify the MD in the acceptable method provided by the hospital, where as before, it would be MD word against RN. There is most likely a way for the MD to acknowledge the message, or at least an electronic stamp showing it was viewed by someone logged in under his/her user ID. If, in court, the MD says he/she was not notified, the nurse is covered. Makes it harder for MD to throw nurse under bus.
The dispute over whether she should have called the MD or if this electronic message was enough, is another issue.
No, the note is not too stuffy.
- 0Nov 24, '12 by BrandonLPNEven with electronic charting, there's still an actual physical chart, right? Or do some places actually have no "plastic and paper" charts whatsoever? Where are consents, doctors orders, med reconcilliations? All just kept electronically, with no paper hard copies? That seems incredibly dangerous.
- 2Nov 24, '12 by BrandonLPNHmm, maybe I'm hopelessly behind the times, but not having a "hard copy" chart or file or whatever seems unthinkable. The electronic record is too vulnerable. I think facilities that rely solely on electronic records will live to regret it.
- 0Nov 24, '12 by mappersQuote from BrandonLPNIt's the law of the land now. Electronic Medical Records that follow the patient is part of ACA.Hmm, maybe I'm hopelessly behind the times, but not having a "hard copy" chart or file or whatever seems unthinkable. The electronic record is too vulnerable. I think facilities that rely solely on electronic records will live to regret it.
- 0Nov 24, '12 by featherzRNNo paper chart at all at my place, and we chart just like the OP, with sending notes to the MD which require them to 'sign' them or they won't leave their inbox. I generally don't use 'please advise', I end my notes with something like "MD sent message regarding refusal" and it shows right below that I sent the message to them for signature. I'm outpatient, so our docs clear their boxes at lunch and after patients are done for the day, so they sign the notes pretty quickly.
- 2Nov 24, '12 by BiohazardBettyAltra, what an excellent point!! I bet you're exactly right about urinating being part of the criteria for discharge... & it might have changed the pt's mind if I had mentioned that to him. Thanks for bringing this up! I'll definitely remember to tell my pts important things like this in the future.