Am being asked to chart an order I didn't receive

Published

Not sure if this is the best forum, but here goes. I'm currently working in home health and helping out a nurse with wound care visits (I am not the case manager). The Patient's wound care order has changed a few times, and we have also had the problem of having to substitute products while waiting for the right wound care supplies to come in. The Case Manager documented all these changes in the care plan, but did not write an official verbal order in the chart. Now my Supervisor is asking me to write the order (some of these changes were over a month ago), because the other nurse is on vacation. But I never spoke to the wound clinic about these issues or orders...is it just me or is this a totally unreasonable request? What would you do? I thought about just calling the wound clinic to get a verbal order but this seems like an unnecessary thing to burden a clinic with when it's a documentation issue on our end. What should I do? Is it reasonable to request that this situation be addressed with the other nurse when they return in a few days?

Note: I have an order for the wound care we are currently doing...this is a retroactive issue for older visits.

caliotter3

38,333 Posts

I see no problem with making the call to get the correct info to write the necessary order. Make certain that the order has the correct date.

JBudd, MSN

1 Article; 3,836 Posts

Specializes in Trauma, Teaching. Has 42 years experience.

Make the call. CYA charting after the fact was not your work/responsibility is unethical and could come back to bite you hard. It is called false charting!

oceanblue52

462 Posts

Appreciate the feedback! I think it was the way it was requested that rubbed me the wrong way, because they just asked me to write it. I certainly have enough common sense to not do that, but will go ahead and call for another verbal. Thanks again :-)

Libby1987

3,726 Posts

Our wound clinic faxes the clinic's visit note that includes the current orders. Check to see if these are already in the chart, or request them. You can do this without interrupting clinical staff. Then all you need to do is put it on your own letterhead for signature.

One thing also to consider, have you've been performing the wound care without an order? Since you're responsible for your own practice and ensuring that you have MD orders for whatever care you are providing, I would be highly motivated to get that order in the chart.