Advice on protecting my license

BarbPick · Dec 31, 2003

was taught to you in Nursing 101.

Be well rested. Learn to be organized. As soon as you come on duty out of report, go straight into your patient's room ,and make sure all have a pulse.

Check Your MAR's first as well as a chart check that all orders have been taken off on your patients.Check Kardex's see if outstanding lab work has or has not been drawn.

See if anyone will be going to the OR in the next 24 hours and start an OR check list.

Check your med cart early to make sure you are not missing meds.

What I should have mentioned first, learn your exact scope of practice from your states Nurse Practice Act.

My husband was a hot dog as a young police officer and crashed 7 police cars in chases. They no longer allow chasing bad guys unless it is an extreme emergency...............Don't be a hot dog work within the nurse practice act.

Good luck,

Barbara

BRANDY LPN · Dec 31, 2003

Chart, chart, chart.

Keep in mind you may incounter this chart again in court or in front of the board, be descriptive, legible, and chart everything you do for each pt. it may not seem like much if youre giving them a cup of H2O but if they later say you never offered them any and its not charted it wasnt done (for an example).

BarbPick · Dec 31, 2003

I hate charting so I must have blocked it. Make sure besides marking off a prn on your MAR, also put it in your notes, just in case you forget to make a mark on the MAR, it saved my *** once.

nurstudnt546, BSN, RN · Dec 31, 2003

Thanks so much for all of your suggestions. I intend on developing these good habits while I'm still a student so I will be better off for it.

I definitely agree with organization - I just can't function without being organized (I've actually developed my own little info forms in word/excel for clinical; of course while still maintaining patient confidentiality).

Being well rested is a must for everyone too. However, I wonder, do any of you (who are already RNs) find this difficult to achieve when you do back-to-back 12hr shifts? Right now it's hard for me to get a good night's sleep the night before an early clinical when I have to stay up and work on my careplan.

I also like the advice regarding doing "extra/backup" charting with nurses notes. This is something I haven't done much of yet but will get right on it this semester.

I sure hope I'll have time to chart the "little things" like giving a glass of water because I'm all for including ALL the details . I'm just so worried that there will be a whole lot of important things to do that I may leave the little things out with the ratios nurses have these days:(.

Once again I appreciate all of your advice it may save my butt one day and more importantly my patients. Keep 'em coming.

PMHNP10 · Dec 31, 2003

nurstudnt546

When it comes to charting, remember clear and concise; avoid first person; present tense. Also, most important, as a student, chart how your curriculum dictates (eg. Q2H). Once you enter the field, chart according to the facility's policy (eg. charting by exception). Deviation from the policy can at the least result in some remediation.

Also, something I learned about lawsuits. While clinical skills are important, studies show that technically skilled nurses (this being by far their greatest attribute) are brought before a court (or BON)more often than kind, caring, nurturing nurses.

Having not had a complaint filed against me, I don't know what all is involved in the process, but from what I hear it takes a pretty bad act (severe negligence, assault, personal misconduct, etc) to lose your license. It seems in the paper my BON circulates, most cases require only warnings or remediation--not that anyone wants that either, but it's not like going before the board is a death sentence.

Originally posted by BarbPick
I hate charting so I must have blocked it. Make sure besides marking off a prn on your MAR, also put it in your notes, just in case you forget to make a mark on the MAR, it saved my *** once.

It's funny, throughout nursing school we are taught to never double chart and yet we find ourselves forced by necessity to do so. Out of curiosity...what is the problem with double charting? Does it give lawyers the idea that something was done twice? Or is it more an issue of the more you write about the same event, the more likely you are to write something in error?

BarbPick · Dec 31, 2003

Pain Medication is getting stronger, more is being given out in oral forms like all the "contin" drugs and break through pain medication is usually percocet.

In the age of Pixix machines that print the exact time a medication is removed from the drawer, the time it is actually administered to the patient is done by audit of the chart, and the print out from th pixix. machine.

I know of a Nurse who was called on the carpet because there was a full hour's difference from the time she pulled out the percocet and it's administration. There were also some other discrepinces that had happened in the hour gap.

They called the BON, I really think they just wanted to get rid of the Nurse. The investigator came looked at the chart and started laughing. It was the night the time changed from standard to day light time.

The nurse was smart enough to write in each patient's nurses notes that the time changed occured.

You can never chart too much. Pain should be doccumented in the MAR, the pain sheet and your nurses notes. If you bother someone with it, oh well! Five years later in court, you will have triple back up.