Vertical Violence on the floor - Page 3

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  1. Jan 18, '11 by
    That is a great question...and obviously one I had! Every seasoned nurse I asked told me they do not normally document such things. Perhaps I would have CYA better if I had told the oncoming nurse ALONG with the charge nurse. I was always taught such comments do not belong in the legal document...I am still contemplating this one....
  2. Jan 18, '11 by
    Quote from LisLis
    Anyway, what guidance can you seasoned nurses give should this situation of a nonfunctioning pump at shift change (or something similar) happen to me?

    How would one document this kind of situation properly and CYA?
    Grab a working pump and get the meds in your pt before you leave or at least have those meds infusing while giving report to the relief nurse with documentation to back it.
  3. Jan 18, '11 by
    Not possible...for reasons stated. Pump needs to be ordered from central, there are not extras kept on floor, and it did not arrive before shift ended. Otherwise there would have been no problem ;-)
  4. Jan 19, '11 by
    Quote from LisLis
    Sorry if this is a bit off topic, but I am a new grad who is currently pouring over books on documenation to cover my butt (although it's a shame that every time we document, we have to write as if every note will end up as part of a lawsuit). Anyway, what guidance can you seasoned nurses give should this situation of a nonfunctioning pump at shift change (or something similar) happen to me?

    I think it was suggested to document that the pump was not working, that you went through the proper channels of seeking a replacement and was waiting for it, passed the task onto the reporting nurse at shift change. I've read that we should never document that "such and such job for such and such patient was passed onto Nurse Jones" because we should never put a specific nurse's name in the record. But, if we don't in this situation, can't that nurse completely deny or just plain forget that we relayed the problem and transferred the task?

    How would one document this kind of situation properly and CYA?
    We put nurses names in the patient record all the time...if someone assists me with a procedure, or if I pass along information to the next shift, you can bet your bottom dollar I am going to document who...otherwise, that nurse can deny you ever told anyone or that they ever touched the patient.
  5. Jan 19, '11 by
    Quote from lobianm
    That is a great question...and obviously one I had! Every seasoned nurse I asked told me they do not normally document such things. Perhaps I would have CYA better if I had told the oncoming nurse ALONG with the charge nurse. I was always taught such comments do not belong in the legal document...I am still contemplating this one....
    This is how I would have charted it:

    1845: Infusion pump found to malfunction. No replacement is available at this time. Spoke to John Doe with central equipment who is currently locating one to be cleaned and brought up to room 1000 stat. Informed Jane Doe, RN in report that patient has LR infusing at ___ ml/hr to be restarted as soon as equipment is available. Communicated event to Susie Smith, RN, charge for AM shift.....Babylady, RN.
    positivern and country mom like this.
  6. Jan 19, '11 by
    Quote from BabyLady
    This is how I would have charted it:

    1845: Infusion pump found to malfunction. No replacement is available at this time. Spoke to John Doe with central equipment who is currently locating one to be cleaned and brought up to room 1000 stat. Informed Jane Doe, RN in report that patient has LR infusing at ___ ml/hr to be restarted as soon as equipment is available. Communicated event to Susie Smith, RN, charge for AM shift.....Babylady, RN.
    Agree ....that's how I would document the event.

    However ... isn't it a sad reflection of our working conditions and work culture ? Having to write a paragraph to protect oneself just because a pump malfunctioned and a relatively routine treatment is expected to be delayed by ? 30 mins.

    The OP's previous work environment sounds like a snake pit. Bet that was a fun place to work and I'm sure she is ecstatic to be out of there
  7. Jan 26, '11 by
    Quote from pedicurn
    Agree ....that's how I would document the event.

    However ... isn't it a sad reflection of our working conditions and work culture ? Having to write a paragraph to protect oneself just because a pump malfunctioned and a relatively routine treatment is expected to be delayed by ? 30 mins.

    The OP's previous work environment sounds like a snake pit. Bet that was a fun place to work and I'm sure she is ecstatic to be out of there
    I agree.

    As a nurse with under 2 years experience, I am having the problem of when I communicate infant condition to certain day shift nurses...instead of communicating my concerns to the physician, more than once, they have been dismissed...not because I was wrong, but because the nurse I communicated concerns incorrectly assumed that I was mistaken without any evidence or personal observation to back it up with. Not too toot my own horn, but I have rarely been wrong with my concerns.

    Once (cannot post details b/c it is too specific), this could have had a fatal outcome for the infant...it was then that I realized that the day shift nurse could always claim that I failed to accurately communicate the infant condition in report (because not everyone reads what you chart)...so from now on, if it is something that needs to be communicated to the physician, I make a final note right before I give report, "Reviewed cardiac/respiratory/feeding issue to Jane Doe, RN in AM report..please refer to cardiac/respiratory/feeding notes."

    That way, I have documented not only my notes but that I specifically brought the issue to the attention of the RN taking report.

    Yes, it is SAD that you have to go that far, but I will be darned if anyone ever accuses me of not communicating needs.