Ok so I go into work this weekend at my LTC weekend job and there is a typed note to nurses telling us from now on we should shred faxes we receive back from md after we have written T.O. and charted it in the nurses notes, so the charts wont be so thick.
I will always write the T.O. and chart it, but I don't think I will be shredding anything that comes across the fax with an MD signature, order, or note on it, cause I think at the point at which the Md writes on a fax it is part of the medical record.
One other really crazy thing , ADON told nurses on our hall that we did not have to do an incident report on one of our "frequent fallers", because it is care planned on the chart.
I wonder if State Surveyors or Lawyers would agree with this, or will they hold us nurses to the minimal standard of the policy and procedure; which states "all falls will be followed with an accident and incident report and investigated". Not to mention neuro checks if fall unwitnessed. (yes I looked up the policy and procedure)
ADON said when asked about this, " Well I just meant if she falls because of her Tias".
I guess now, not only can I destroy part of the medical record, and circumvent policy and procedure , I can dx too.