charting MD aware when you were not the one responsible to call MD as per facility policy

[Yoyo1313]

I recently took a night shift RN position in a ltc facility. Per the policy at facility I notify RNS of any issues and the RNS is responsible to call MD yet they want me to document MD aware. It makes me feel really uncomfortable and I think of legalities. Any insight would be great since its facility policy yet I believe its not my responsibility to chart MD aware since I never called them. I also feel its incomplete documentation since I write MD aware but just leave it at that nothing follows because I don't get any new orders or any instruction since I never called MD the supervisor is supposed to...so I feel the supervisor should chart it then.

[Spidey's mom, ADN, BSN, RN]

May I assume RNS=RN Supervisor? Never saw that before.

I was the RN Supervisor/ER nurse . . .never heard it before either.

Quote from MunoRN

There is absolutely nothing wrong with charting "MD aware per report of Sally

RN

".

Muno . . . . . unless I'm listening on an extension or they are speaking on speaker-phone . . . I have no idea if Sally RN really is talking to the doc.

[MunoRN, RN]

Muno . . . . . unless I'm listening on an extension or they are speaking on speaker-phone . . . I have no idea if Sally RN really is talking to the doc.

That's why you would include the qualifier (per report of Sally RN) that you don't have first hand knowledge of the conversation, you're only documenting what another RN reported to you.

Same idea as charting that a med was given but you're only charting it per the report of another RN, MD, etc.

[Spidey's mom, ADN, BSN, RN]

That's why you would include the qualifier (per report of Sally RN) that you don't have first hand knowledge of the conversation, you're only documenting what another RN reported to you.

Same idea as charting that a med was given but you're only charting it per the report of another RN, MD, etc.

Yeah I guess. . . . . still makes me uncomfortable.

[icuRNmaggie, BSN, RN]

No one makes anyone do anything.

In this situation I would document the non urgent symptom or concern. An example:

" Pt's FSBS running over 200 since 11/5/2014 @ 2100. Dayshift nurse Suzanne Smith RN updated and she agreed to inform Pt's primary care physician, Dr Jones, during her shift."

Charting MD aware is not just a false statement, it's meaningless without a note that specifies what the MD ordered for this person.

[tyvin, BSN, RN]

SOMEONE is on call for the group, you can bet there is a Dr SOMEWHERE prepared to take any needed calls

I believe this person is talking non-emergent issues. Are you going to call the on-call at 03:00 about how a patient is refusing their Abx's or that you want to institute Ensure due to weight loss? I don't think any RN who is licensed is not going to "NOT" call a doc when an emergency develops. There are multiple issues that RNs disagree about calling the on-call about. For instance, when a patient dies I do call the on-call; others wait to call the office.

[psu_213, BSN, RN]

I think it would be quite appropriate to chart "Sally Smith, RN informed of XYZ. Sally Smith, RN reports that she will inform S. Jones, MD." I charting this not because I don't trust Sally, but because I know stuff happens that may prevent Sally from making the call to the MD. If it is a critical issue (like a grossly abnormal lab result), the RN must call to notify the doctor when the RN gets the result…even if that means waking the doctor up.

[k.cam]

Every facility is different in the wording they use. The key is charting that you have endorsed the responsibility to another person.

"Endorsed to Jane Smith RNS, will inform MD in AM."

There is nothing wrong with charting that someone has told you that they did something, as long as that is what you write.

"Per Jane Smith RNS, MD made aware."

[Hi2Jenn]

I think what most posters are missing is a context. There are many things that occur on the nightshift that by regulation must be reported to the provider. However, I don't think you're going to call them at 3 am to say, Ms.Smith fell out of bed. The only injury was a skin tear. I believe those are the situations she is speaking about.

I would also further say, that you should not document "MD aware" You should specify WHO you spoke to. Name and credentials. Just FYI.