Permanent documentation... "Please advise"?

[BiohazardBetty]

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 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??

[PghRN30]

Im a new RN myself, but having detailed e charting drilled in through school, I would say that I would have one further addition "pt educated on risks of continuted foley, communicated understanding of risks, still refused foley removal" and then under pt education charting charting the same education. More of a CYA situation, proof that you did associated teaching that should be done.

[RockinChick66]

I 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?

I agree with you on this. Drs do not read our nursing notes. At my hospital, we use Epic EMR and we have a place to put "sticky note" to physician which is just like a post it note on the chart. It is not part of the patients permanent record.

I would have addressed why this pt felt he could not void. Also I believe pt teaching is important in this situation and that he should have been instructed that he is 'at risk' for infection by leaving the foley in.

In the end, we must follow physicians orders and if the patient refuses in this situation, then I believe it's the responsibility of the nurse to notify the Dr. I have notified my Drs in same situations as this. I don't care if its Christmas Day, that's what they get paid for.

[akulahawkRN, ADN, RN, EMT-P]

Im a new RN myself, but having detailed e charting drilled in through school, I would say that I would have one further addition "pt educated on risks of continuted foley, communicated understanding of risks, still refused foley removal" and then under pt education charting charting the same education. More of a CYA situation, proof that you did associated teaching that should be done.

In terms of charting, that's about how I'd chart the refusal, by adding that kind of information into the note. I would have also sent a note to (or personally advised) the physician who was covering the patient so that a person that is medically responsible has been made aware of the refusal, cc the physician that ordered the D/C of the foley (in this case). There are some differences between paper and electronic charting... but the content and intent of this charting would be the same: documenting that the patient refused to have that particular procedure done, was educated about the need for it, and still refused... and that appropriate medical personnel were advised about the refusal.

Not yet an RN, but that's my take on the charting end of this...

[Ntheboat2]

I think the note sounded fine!! Not stuffy at all. You know, I've been told that even the word "refused" shouldn't be used, but instead the word "declined" should be used. I'm sorry, but I think there's a huge difference in declining and refusing! I've heard the same thing about using the word "complain." Supposedly, saying the patient complained of pain is disrespectful and a word like "reported" should be used. Oh, whoops, I said "patient" which is also a no-no! They are "clients" now.

[edmia, BSN, RN]

I think the note sounded fine!! Not stuffy at all. You know, I've been told that even the word "refused" shouldn't be used, but instead the word "declined" should be used. I'm sorry, but I think there's a huge difference in declining and refusing! I've heard the same thing about using the word "complain." Supposedly, saying the patient complained of pain is disrespectful and a word like "reported" should be used. Oh, whoops, I said "patient" which is also a no-no! They are "clients" now.

Client declined morphine IVP for reported pain of "200" on 0 to 10 scale. Client asked for Dilaudid IVP and suggested this RN should also push 50 mg of diphenhydramine "right after" administering Dilaudid. MD has been notified of client's needs.

LOL.

[Altra, BSN, RN]

I think the charting itself was fine, although the addition of "please advise" is unusual. Anyone reviewing that chart would conclude that that was the "official" means of communication between nurse and physician and would likely have all kinds of questions about that process, how long it takes, and the nurse's judgement on what to do next if a reply was not prompt. The physician did need to be notifed, though, and whether or not to do this on the evening of Thanksgiving is/was a judgement call.

At first glance it seems a no-brainer that refusal of removal of the Foley is not a critical change and so can wait till morning ... but removal of the catheter and successful voiding without assistance is probably a major criteria for discharge for this patient. And that progress toward discharge has now been delayed, possibly adding an additional day to the patient's length of stay. If I had this patient - that would have been the focus of my discussion with him/her. Infection risk is very real to us as healthcare professionals but it is a far more nebulous concept to laypeople.

[mappers]

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.

[CoffeeLoveRN]

I think what you said is fine. If a patient refuses anything, that is all you can do is document, state what the patient said, state that you educated the patient on risks and benefits of foley catheter and they continued to refuse removal.

If you had continued to touch the patient and remove the foley, you would be entering the territory of battery, which is indeed a legal problem.

[Susie2310]

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.

The OP asked in his/her last sentence "How would you communicate this info & ask for advice?" Hence the replies.

[BrandonLPN, LPN]

Even 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.

[mappers]

I am no longer at a hospital, but where I work, everything paper (consents, insurance cards, etc) are scanned into the electronic record. The paper is then shredded.

[BrandonLPN, LPN]

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.