Documenting

  1. ON MY SHIFT I FOUND A PATIENT DOWN AT SIDE OF BED. DIED OF SUBDERMAL HEMATOMA THREE DAYS LATER. THE RN ON SHIFT MADE ALL THE NOTATIONS REGARDING THE INCIDEN, EVEN THOUGH NOT THE ONE WHO FOUND PATIENT. SHOULD I HAVE MADE SOME DOCUMENTATIONS REGARDING FINDING THE PATIENT?
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  2. 18 Comments

  3. by   shannonRN
    at my facility, there are incident/risk reports. when it comes to a patient who has fallen, the person who witnessed the fall or found the patient on the floor is supposed to fill it out. if you facility doesn't have a form like this then i would think that the primary nurse documenting the event would be okay. i think it depends on your facility's protocol.
  4. by   RUNZEL
    IN THE MEDICAL RECORDS, IT LOOKS LIKE I DID NOTHING AFTER FINDING THE PATIENT. THE RN DOCS "FOUND DOWN" ONLY . SHOULDN'T IT BE NOTED BY WHO?
  5. by   shannonRN
    i am not a legal expertise, so i don't want to steer you in any particular direction. if i read a nurse's notes and it said "found down." i would assume that the nurse who wrote it found the patient down. but that is just me. i don't know what to tell you....
  6. by   RUNZEL
    NO INCIDENT REPORT WAS FILLED OUT! THEY ARE LOOKING AT ME FOR COVERING UP. THE RN DOESNT "REMEMBER "WHO FOUND THE PATIENT
  7. by   BadBird
    Why don't you fill out a incident report now,list the date and time you found the patient, who you notified, any tests or treatment the patient recieved.
  8. by   RUNZEL
    thanks, i will do that, but it still looks bad. i guess i should have made of doc of my own.
  9. by   renerian
    Wow an incident report seems like it should be recorded by the one who found it. You can always fill it out and date it in the body with the date and time you found them and an explanation why it was done late. Better late than never to CYB. We always had to document falls on incident reports.

    renerian
  10. by   renerian
    I meant to say found them.......not it.........oops typo. Good luck to you in resolving this situation.

    renerian
  11. by   RUNZEL
    since i didn't fill out an incident report myself, can i find out IF and WHO did, by any other MEANS than asking the shift nurse,
  12. by   Youda
    In your profile, you say your profession is "caregiver." Does that mean you are not a licensed LPN or RN?

    If you are not licensed, then it was appropriate for the RN to fill out the report and document the incident. Since there was a death involved, I'm sure you will be interviewed at some point, along with anyone else who was a duty. If this is a LTC facility, the state must be notified of an accidental death. You might make some notes to yourself about everything you remember that happened, so it will be fresh in your mind for later.

    If you are licensed, I'll revise my "free advice."
  13. by   RUNZEL
    not licensed, but screwed, thanks for the input
  14. by   Youda
    Why do you feel that you are screwed? It sounds to me like you are caring and concerned. Did I miss something?

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