why record lab results in the nurse's note

[Pediatricjo]

Does any other facility require you to enter non-critical values into the nurse's note? We have now placed a section in the nurse's note for entering abnormal lab values, did you call the doctor & what resulted, why you didn't call the doctor. There is possibly a new policy coming that would require us to enter each lab value. At this time there is no definition of if it is each & every lab value or a particular out of range but not critical value. We have a place to enter critical lab values & what we did about it.

[Pediatricjo]

We have a critical value note for those items. In this we either notify the doctor & what was done or we didn't & why we didn't. It's all electronic charting so it's point-&-click. THis is new. THis is contained within the body of the nurse's note & at the moment would require the nurse to printout each lab for that draw/time, enter the abnormal (out-of-range) values (no matter what or how many) & then note if we called the doctor & what was done or we didn't call the doctor & why not. We have the potential to autofeed the lab (i.e. cbc) into the note because they do with the doctor's progress notes. One would have to scroll through the entire note to see if we did anything else but oh well. I do like ClassicDames suggestion from their facility & will bring this up tomorrow. It seems like a lot less typing. Not to mention less chance of being found in violation of a policy. Thank you all so much for your advice. I will post what gets decided & why.

[Pediatricjo]

Just an update. The committee met again and the proposer was there to explain that it does not have to be each abnormal lab value. One could click the item to say they notified the physician of abnormal lab or x-ray & what was done. There is a space to type which values or results you notified them of but it is not mandatory. Hopefully the policy will reflect this also. Thank you so much for your feedback.