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Discussion

A few questions on documentation

When documenting that during oral care of a patient who is npo I observed what appeared to be areas of ulcers on a patients upper and lower gums (this was not documented by other care givers nor was it mentioned in daily shift report from the previous nurse). I notified the Supervisor. I know I must include in my note what I did as my intervention but it was 2 in the morning. Is supervisor notified sufficient or do I need to call the MD that late at night for a Nystatin swish order? What do you do for a problem that needs addressed but it probably could wait until the morning? Do I fax a request to the MD's office requesting a order for this? Can anyone give me advice on how they would handle and document this. Thanks

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    There are different regulations in different facilities and some drs have specific ways that they want something done. If there is not a standing order, ask your supervisor or another nurse on the floor what protocol to follow. That way you can be sure you aren't making a mistake.

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    I would document - communicated findings to oncoming shift. Will notify dr in AM.

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    Good Catch!! Congrats on initiating corrective measures that will certainly make a difference in your patient's quality of life. Anyone who has ever had a mouth ulcer will certainly understand how painful these can be.

    Agree with PP's -- unless you have a reason to suspect that the communication will not be relayed appropriately to the physician, it's best to document and ensure that the day shift notify the physician. Also, be sure to update the patient's plan of care to include this new finding.

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