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

Specialties LTAC

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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.

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Specializes in retired LTC.

Is there something missing here that I'm not seeing? You can't chart something if you didn't do it. You could chart something like "MD to be notified by next shift". But I'm even not comfortable with that. I would not be charting as you describe. Having been an 11-7 nurse for a loooong time, I made my own phone calls. If it was something that needed to be called, I did it myself.

Timing my calls was always delicate. If something could wait, I'd call 6am or so. I figured that the MD was awake & getting ready for work. But if it was something that I felt needed addressing right then, I'd call then, regardless...

Very rarely did I ever leave a phone call for 7-3 to make. And it was only because I trusted the 7-3 nurse 100%. Again I figured if the issue concerned me or my family, when would I expect the call to be made. The same thinking guided my calls to family.

Sorry, but in no way, shape or form would I chart something I hadn't done. Maybe like I commented "Susie Sunshine, RN on 7-3 to notify MD". I'd be absolutely sure that that nurse knew she was to take on the responsibility of the call. Susie seeing her name in the chart might make her a bit nervous to know she was now the notification delegate - she's responsible now.

I think I'd just make the calls myself. Worst thing to happen would be for the MD (family) to call back on the next shift. Oh well...

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Specializes in Emergency Department.

I will not document something that I'm not personally aware of, from the standpoint of me feeling that I would be 100% comfortable sitting on the witness stand testifying about it. How I would approach this may or may not be how you would approach this... but I would document something like the above in a manner similar to: "(patient issue developed), RN Supervisor notified who stated MD will be notified by RN Supervisor." Then when I check back with the RN Supervisor about the MD notification, if I'm told that the MD is now aware, then I'll chart: "Per RN Supervisor, MD is aware of (patient problem)."

This way I'm charting what I know and what I will be 100% comfortable testifying in court about. If the RN Supervisor did NOT actually notify the MD, then my documentation will point to that being the break in the chain, not me. I will not usually write another person's name into the patient's chart unless it's absolutely necessary and for a specific purpose. If an attorney needs to find out who the specific people are, they can subpoena the employee shift records.

IMHO, if your facility's SOP's direct you to chart things that you can not personally attest to, then you need to find another employer quickly. If you can not find a SOP that directs you to do that (you probably won't) then that's essentially an unwritten rule and those have a habit of disappearing when you need to rely on such a rule to protect you if you're being sued or are under formal investigation.

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Specializes in Transitional Nursing.

I'm learning, so forgive me.

Why can't you chart "Notified Saly, RN per facility protocol, who notified MD" ?

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Specializes in retired LTC.

Hey OP. Question- are you supposed to be doing this charting IN ADVANCE - like before you go home?

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Specializes in HH, Peds, Rehab, Clinical.
I'm learning, so forgive me.

Why can't you chart "Notified Saly, RN per facility protocol, who notified MD" ?

How do you know Saly, RN really did notify MD? Why isn't OP just doing it herself? I'm thinking OP isn't a nurse?

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The facility does not want night shift nurses calling MD we are to call our RNS like I said and they are to call MD. I don't know if they do or don't call MD...I just started there in Sept and feel uncomfortable with this practice bubut everyone does it without question...I think its time for change I did it twice and felt uncomfortable with it....I'm finished now....they will have to discipline me I guess because if the RNS is to call the MD the RNS can document they did or didnt and what orders were received.

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Specializes in HH, Peds, Rehab, Clinical.

Are you an RN?

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Yes I am a RN!

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Specializes in HH, Peds, Rehab, Clinical.

Wow. There are times that an MD NEEDS to be called, no matter what time it says on the clock

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Specializes in Cardiac Care.

Rules of charting state that you document your observations, actions, etc. NO WAY would I document that the MD was aware of anything unless I PERSONALLY notified that doc. Your best action here is to state that you notified the supervisor. Period. If facility policy states otherwise, I'd find another facility. That policy is wrong, and YOU have a license to protect.

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Specializes in RN, CHPN.

If the MD needs to be aware of something that happens while you're on duty, then make him or her aware of it yourself. Never hesitate to call an MD with a valid concern. Give no thought to what time it is -- if it's urgent, you have the right and the responsibility to inform them of their patient's status.

If it's not urgent, then wait until a decent hour. But never, never, never document anything you didn't do. I don't care what the 'policy' is -- if that's the policy, it needs to change. It's your license, and your patient's well-being, on the line. If anyone questions your unwillingness to document something you didn't do, I would question them.

I (barely) remember my very first job as an RN. Kidding, I will never forget it. I had to call a doctor at 3 A.M. and I was scared to death. I thought he'd chew me out, but I knew I had to do it anyway. Not only didn't he chew me out, he showed up 30 minutes later and spent the rest of the night with the patient. That's beyond rare, but it happened. The patient was a 17 year old with leukemia. Brings a tear to my eye just to think of it. A good doctor wants to know if there's a problem. Even if they don't, it's their responsibility. If they're on call, they're on call.

One of the most common medical errors is 'failure to rescue,' which is generally defined as the lack of an appropriate and timely response to a change in a patient's condition. If you need to call an MD, don't hesitate.

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