Permanent documentation... "Please advise"?
- 0My 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 note" that becomes a permanent part of the patients chart... Which the patient, pt's family, & attorneys could have access to if needed. Before I could just stick a post-it on the front of the chart to say "what do you want me to do about xyz?" My question is: How formal or how professional should those event notes be? For example, today I had a patient refuse to have his Foley catheter removed when I told him there was an order to remove it. At the end of my shift I put in an event note that said "Patient refused Foley catheter removal. Patient stated he is unable to urinate on his own & is unwilling to attempt to use a urinal or go to the bathroom. Please advise." Since everyone who cares for that patient has access to his chart and this note, one of the other nurses read what I said and said it sounded "stuffy" but how else should I tell the doctor what's going on & ask for a plan of action with out saying "This guy is lazy & says he doesn't want to get up & pee. What should I do?" ...And I won't be back to work for 5 days, so it's not really ME who needs to know what to do. Also, I want my documentation to be clear, concise, consistent, and professional enough that I wouldn't be embarrassed to defend it in court, if the need ever arises. How would you communicate this info & ask for advice??
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- 2Nov 23, '12 by loriangel14 GuideI think the note you wrote was fine. It didn't sound stuffy, it sounded professional. Is there no other way to communicate with the MD? In a case like that I would call the doc and ask for further instructions. We have electronic charting but we still have paper charts.
- 0Unfortunately, unless we catch them on the floor or page them, there's no other way to make sure they get the message... Since the pt flat out refused to have the catheter removed, I didn't feel it was important enough to page the Dr at home... But I'm a new nurse & that might have not been the best choice... Would you have paged the doctor in this case?
- 6Nov 23, '12 by madwife2002 Senior ModeratorIf the order is in the chart and it is not done, then you need to document why? Also you would need to page the dr and explain why it was not done so you can confirm the dr knew, and you can document this also.
Yes you should have paged the Dr, always try to let them know verbally if something is not carried out! Then you need to document that you contacted the Dr or at least attempted to and the time you called.
- 2Nov 23, '12 by KelRN215I have always used electronic documentation in some form, although our nursing notes did use to be on paper when I first worked in the hospital. In the situation you describe, I would simply text page the MD and say "FYI, Mr. Smith refuses to have his foley removed." I would not write an event note requesting advice from the MD because I know that the MD would never read it... at least not at my former hospital. The only people who read nurses' notes were nurses. Though I would have included in my nursing note something like "order received to d/c foley cath, pt refuses, MD aware."
I don't understand why having nursing notes on the computer makes it so complicated to communicate with the MD though. You can call, email or speak to them when they come to the unit, can't you?
- 0I alway appreciate the excellent responses I get from everyone here! Thank you!! I'm not exactly asking whats the best way to contact an MD, since i'd imagine all of our facilities are different... I'm mostly asking the appropriate language to use when the documentation will be permanent. A texting system to communicate with doctors would be wonderful, but we don't have that. We also don't use email to communicate with them (as floor nurses at least)... The note I entered wasn't a "nursing note." It's an event note that is specifically used to communicate info to others about the pt. We can assign a co-signer option so that the note automatically pops up the next time whoever you assign as a co-signer logs into the system. I also charted the incident appropriately in my nursing notes, but like other posters have said, the doctor would never read that.
I understand that several of you think the doctor should be paged ASAP to be notified if a pt refuses a catheter removal, & if it hasn't been 7pm on thanksgiving night I might have paged him, but I really didn't think anything could be done immediately to fix the problem... Was the situation more emergent than that? There were no s/s of infection, catheter was patent, surrounding skin was intact, oncoming nurse notified... Just short of the doctor telling me to force the man to let me remove it (which clearly wouldn't happen), what could be done? I'm usually calling the doctor saying pts are begging to have their foleys taken out!
- 0Nov 23, '12 by mariebaileyIn my prior places of employment, we did not have secure email, and those emails were considered public property subject to the "Freedom of Information Act". It was just understood that what we communicated via email was to be much more formal and objective than what may transpire in person b/c we had a potential audience. I wouldn't worry about being "stuffy".
I can see what the other posters are saying; if it is an urgent or emergent situation, documenting an attempt to communicate with the doc by another route seems appropriate.
There are some CNEs you can take online on charting; you can view them for free, but you have to pay for credit. The advice in these courses may be commonsensical to you, but I found them helpful only 5 years into nursing:
Document It Right: A Nurse's Guide to Charting | 60076 > Continuing Education Unit at Nurse.com
Every Nurse is a Risk Manager | CE105-60 > Continuing Education Unit at Nurse.com
Document It Right: Would Your Charting Stand Up to Scrutiny? | CE510 > Continuing Education Unit at Nurse.com
- 1Nov 23, '12 by nrsang97Quote from loriangel14ExactlyI think the note you wrote was fine. It didn't sound stuffy, it sounded professional. Is there no other way to communicate with the MD? In a case like that I would call the doc and ask for further instructions. We have electronic charting but we still have paper charts.