Addendums

[0121Mednurse]

I want to know your thoughts regarding management creating addendums on progress notes written by another? Please share your opinions. Thank you

[Davey Do]

Interesting and something I've not run across.

As long as it's all above board with authorship and isn't subjective, I see no problem.

[JKL33]

Need example...

[sideshowstarlet, BSN, RN]

How does this addendum work? Is it something like you charting that you gave someone 2 Norco's at 1355 (5 minutes before the end of your shift) for pain 8/10, and then your manager writing an addendum at 1440 stating that patient's pain decreased to 2/10? I wonder why the manager would write an addendum rather than a separate progress note? 

[0121Mednurse]

This is the progress note a registry nurse wrote.  She was assigned to a behavioral unit.

During rounds nurse observed the resident in his room with a female resident. They appeared to be having a personal conversation as the male.  resident was observed to be holding her by the arm. The nurse stood at the door way and offered to show the female resident to her room and help her get ready for  bed.  She made her way out of the room with out incident. Male resident became upset and shouted “stay out of it!”

[sideshowstarlet, BSN, RN]

On 7/18/2022 at 11:37 AM, 0121Mednurse said:

This is the progress note a registry nurse wrote.  She was assigned to a behavioral unit.

During rounds nurse observed the resident in his room with a female resident. They appeared to be having a personal conversation as the male.  resident was observed to be holding her by the arm. The nurse stood at the door way and offered to show the female resident to her room and help her get ready for  bed.  She made her way out of the room with out incident. Male resident became upset and shouted “stay out of it!”

So, what was written in the addendum?

[0121Mednurse]

For clarification purposes: Today writer spoke with jane doe registry nurse on duty for 7/12 6p-6a for clarification purposes of note written 7/13/22 at 12:29a. Jane (nurse) stated that she observed female resident in Mr. *** room and they (the two residents) were having a conversation in a normal tone and it was noted that Mr. *** was holding female resident arm. Jane(nurse) could not specify what the conversation was pertaining too but did note that the female resident was not in distress because of her mannerisms, jane (nurse) immediately separated the two residents by offering to assist female resident to her room because it was bed time and that is when Mr. *** became upset. Female resident was cooperative and calm. Jane (nurse) stated that English is her second language and that the term "Intimate" meant more so "Private 1:1 conversation". Jane doe (nurse) is registry and was uncertain when she would be in the community again). **** RN DON

[Davey Do]

1 hour ago, 0121Mednurse said:

JANE DOE (NURSE) IS REGISTRY AND WAS UNCERTAIN WHEN SHE WOULD BE IN THE COMMUNITY AGAIN). **** RN DON.

Yeah- that's really not appropriate to a patient's chart, as it is a status with the nurse.

[0121Mednurse]

As a side note, the nurse was assigned to the unit 3 consecutive nights and each time she received report, she was told to monitor the resident inappropriate behavior with  multiple female residents for quite sometime . Nothing has ever been documented . The nurse receives A phone call from the Director of Nursing And was told to never chart something like that again Because it makes the facility look Like it’s at fault. 

[sideshowstarlet, BSN, RN]

42 minutes ago, 0121Mednurse said:

As a side note, the nurse was assigned to the unit 3 consecutive nights and each time she received report, she was told to monitor the resident inappropriate behavior with  multiple female residents for quite sometime . Nothing has ever been documented . The nurse receives A phone call from the Director of Nursing And was told to never chart something like that again Because it makes the facility look Like it’s at fault. 

It sounds like Jane did the right thing in separating the residents. I probably would have elaborated in the note whether or not the female resident felt comfortable with the conversation, but then I don't have to chart in my second language. And at fault for what, exactly? It doesn't sound like much of anything happened. The nurse separated the two residents, the male resident protested verbally, but it didn't seem to go beyond that. 

[Davey Do]

1 hour ago, 0121Mednurse said:

The nurse receives A phone call from the Director of Nursing And was told to never chart something like that again Because it makes the facility look Like it’s at fault. 

Objectivity in charting is reporting the facts and psych patients will display inappropriate behavior, so the DON needs to understand this, or is otherwise delusional.

A delusion is a false fixed belief, in spite of evidence to the contrary.

[JKL33]

On 7/18/2022 at 12:05 PM, 0121Mednurse said:

For clarification purposes: Today writer spoke with jane doe registry nurse on duty for 7/12 6p-6a for clarification purposes of note written 7/13/22 at 12:29a. Jane (nurse) stated that she observed female resident in Mr. *** room and they (the two residents) were having a conversation in a normal tone and it was noted that Mr. *** was holding female resident arm. Jane(nurse) could not specify what the conversation was pertaining too but did note that the female resident was not in distress because of her mannerisms, jane (nurse) immediately separated the two residents by offering to assist female resident to her room because it was bed time and that is when Mr. *** became upset. Female resident was cooperative and calm. Jane (nurse) stated that English is her second language and that the term "Intimate" meant more so "Private 1:1 conversation". Jane doe (nurse) is registry and was uncertain when she would be in the community again). **** RN DON

IMO the whole note is better suited to an incident report (I.e. it is basically an investigation of a situation that someone thought could be a legal risk), but the last two sentences are definitely not appropriate for a patient chart and on top of that would seem to be completely useless information.