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Asked to change my Nursing Note...

Updated | Posted

Has 7 years experience.

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Hi guys, I just wanted a sounding board for this. I worked this weekend as a Supervisor, I’m an RN. We had a patient who needed Narcan, he had an order for it and we have a Narcan policy in the building. I went to the Med room to get it and it wasn’t there, 911 was called and the patient ended up getting admitted to the hospital. I documented that the Narcan was not given because there was none in the building and MD Informed.  I documented that I informed the DON, who stated that she had the pharmacy remove the Narcan from the floor. I included that I sent the order to the pharmacy to be filled for house stock. I got a nasty email this morning saying to change my note to just say, “Narcan not given and unavailable”. 

I think that’s unacceptable, it’s a doctors prescribed PRN medication that we were not able to give because it was removed from the floors and the DON had not communicated that with any of us (and I’m a supervisor). When a patient is missing a medication, I always charted the reason why it wasn’t given and included the resolution- meaning order sent to pharmacy etc. I feel like I protected myself and my license, but I’m uncomfortable changing my note. Let me know what you guys think... thanks 

Sour Lemon

Has 9 years experience.

5 minutes ago, ceileann said:

Hi guys, I just wanted a sounding board for this. I worked this weekend as a Supervisor, I’m an RN. We had a patient who needed Narcan, he had an order for it and we have a Narcan policy in the building. I went to the Med room to get it and it wasn’t there, 911 was called and the patient ended up getting admitted to the hospital. I documented that the narcan was not given because there was none in the building and MD Informed.  I documented that I informed the DON, who stated that she had the pharmacy remove the narcan from the floor. I included that I sent the order to the pharmacy to be filled for house stock. I got a nasty email this morning saying to change my note to just say, “narcan not given and unavailable”. 
 

I think that’s unacceptable, it’s a doctors prescribed PRN medication that we were not able to give because it was removed from the floors and the DON had not communicated that with any of us (and I’m a supervisor). When a patient is missing a medication, I always charted the reason why it wasn’t given and included the resolution- meaning order sent to pharmacy etc. I feel like I protected myself and my license, but I’m uncomfortable changing my note. Let me know what you guys think... thanks 

I think “narcan not available” along with your alternate action (calling 911) would have been more appropriate. It's really not your place to investigate and assign blame, much less chart the results of your investigation on the patient's medical record. Your additional details would have been better included in an internal incident report. 

As far as changing the note, that's a bit tricky. I don't know what sort of charting you have, but with most electronic charting there's a record of any changes made. I'd be reluctant to change something that was accurate, even if I realized that it was a bit overboard after the fact.

Cdonocdo

Has 7 years experience.

That is why I’m reluctant to change it. I’m the SDC/ADON so it is my role to do the investigation. It may be over the top, but when I was charting I was infuriated that when I called the DON to let her know what was going on- she very casually stated she had the pharmacy remove them... this really needed to be communicated with staff. The patient had received a total of 16mg of Dilaudid in the 24hrs prior and NEEDED the narcan.  

2 minutes ago, ceileann said:

That is why I’m reluctant to change it. I’m the SDC/ADON so it is my role to do the investigation. It may be over the top, but when I was charting I was infuriated that when I called the DON to let her know what was going on- she very casually stated she had the pharmacy remove them... this really needed to be communicated with staff. The patient had received a total of 16mg of Dilaudid in the 24hrs prior and NEEDED the narcan.  

That’s what incident reports are for! 

Agree with all the above.

No matter how you charted it, what you've already written will be available; that's always been the rule. Even if handwritten documentation you are only to put a single line through it and note that it was erroneous, not obliterate it.

I would have to say that I doubt I would change it at this point, because doing so only makes it look like you originally documented something that was factually incorrect, which, as far as you know, you didn't. I do agree it could be considered procedurally incorrect, though.

Cdonocdo

Has 7 years experience.

I’m going to redact my note so you can see what I charted, I did not include that the DON had not informed staff. 

Cdonocdo

Has 7 years experience.

OK here is my redacted note- I took out all PT identifiers... I kept the charting professional and discussed facts only.

This nurse assisted in response to PT's change in status, PT was in his room at 930am sitting in bedside chair. CNA working with PT alerted PT's nurse that PT had an acute change in status, PT's nurse entered room and PT was sliding out of bedside chair. PT was convulsive and tremulous, diaphoretic, pale pallor, RR irregular and shallow 8-10/min. PT's eyes were bulged open, pupils enlarged and fixed, PT stated he did not feel well. FSBS collected by PT's nurse, 263. PT's nurse collected vitals, POX 99% on RA, 134/98 HR irregular, showing range from 39-74. Palpated by nurse, pulse fast and thready. PT c/o 9/10 pain to lower back, had received PRN Dilaudid 2mg at 8am. PT currently has an order for PRN Dilaudid 2mg Q4h, PT received max dosage yesterday for c/o 8-9/10 lower back pain with little to no relief from Dilaudid. PT currently has spinal stim implant for pain management. PT has PRN order for Narcan nasal spray. This nurse, weekend supervisor and PT's nurse attempted to locate Narcan on the floor in the medication cart, the rapid response pack and the medication room- Narcan was unable to be located and not present on the floor for administration to be possible prior to EMT arrival. Emergency services called, EMS arrived approximately 3 minutes after call- EMS unable to get rhythm strip, HR thready and irregular. PT continued to be diaphoretic and speech rambled. DON contacted regarding Narcan not being readily available on the floor for emergency use, stated to weekend supervisor that the Narcan was in an E-kit and the pharmacy had removed the E-kits from the building recently d/t change in pharmacy. STAT order for house supply of Narcan sent to pharmacy to have medication available in house. This nurse contacted ER, spoke with Dr. AJFAJFLAKJFLAJK- PT was found to be in A-fib upon arrival to ER, HR 180-190bpm. Dr. AKJFLKAJLDK stated that the PT is being admitted to CCH. Pt's wife contacted and updated regarding acute transfer to ER.

6 minutes ago, ceileann said:

OK here is my redacted note- I took out all PT identifiers... I kept the charting professional and discussed facts only.

This nurse assisted in response to PT's change in status, PT was in his room at 930am sitting in bedside chair. CNA working with PT alerted PT's nurse that PT had an acute change in status, PT's nurse entered room and PT was sliding out of bedside chair. PT was convulsive and tremulous, diaphoretic, pale pallor, RR irregular and shallow 8-10/min. PT's eyes were bulged open, pupils enlarged and fixed, PT stated he did not feel well. FSBS collected by PT's nurse, 263. PT's nurse collected vitals, POX 99% on RA, 134/98 HR irregular, showing range from 39-74. Palpated by nurse, pulse fast and thready. PT c/o 9/10 pain to lower back, had received PRN Dilaudid 2mg at 8am. PT currently has an order for PRN Dilaudid 2mg Q4h, PT received max dosage yesterday for c/o 8-9/10 lower back pain with little to no relief from Dilaudid. PT currently has spinal stim implant for pain management. PT has PRN order for Narcan nasal spray. This nurse, weekend supervisor and PT's nurse attempted to locate Narcan on the floor in the medication cart, the rapid response pack and the medication room- Narcan was unable to be located and not present on the floor for administration to be possible prior to EMT arrival. Emergency services called, EMS arrived approximately 3 minutes after call- EMS unable to get rhythm strip, HR thready and irregular. PT continued to be diaphoretic and speech rambled. DON contacted regarding Narcan not being readily available on the floor for emergency use, stated to weekend supervisor that the Narcan was in an E-kit and the pharmacy had removed the E-kits from the building recently d/t change in pharmacy. STAT order for house supply of Narcan sent to pharmacy to have medication available in house. This nurse contacted ER, spoke with Dr. AJFAJFLAKJFLAJK- PT was found to be in A-fib upon arrival to ER, HR 180-190bpm. Dr. AKJFLKAJLDK stated that the PT is being admitted to CCH. Pt's wife contacted and updated regarding acute transfer to ER.

None of the bolded is appropriate for the patient chart. It should be documented in an incident report. 

Best to be more concise, just my personal opinion.

[This scenario isn't highly suggestive of a need for STAT narcan...although not wrong to think of it.] Agree with the above, everything bolded should've been left out.

Cdonocdo

Has 7 years experience.

OK, thank you for your feed back. I just wanted a sounding board, but you are right I'll remove it from my note. I'm just frustrated because if I fill out an incident report, it just goes to the DON and nothing will be done. 

I’m fairly certain the report goes up the chain. Also, agree with JKL, I don’t think Narcan was the right intervention in the first place. Your assessment does not support it so making a big stink about it may bite you in the butt. That being said you aren’t wrong in thinking that Narcan should be immediately available if narcotics are being administered. 

Your irritation is certainly understandable.

But...both in the real-time care of such an acute situation and in the integrity of the chart you have to put all of that to the side. The instant you find out that X isn't an option, you have to move on, for the patient's sake.

Additionally, the way you wrote your note could be criticized for going into such detail about the narcan investigation when it is not clear who was doing what, when. Were you the one primarily responsible for assessing the patient, were you in charge of the patient scenario--and also doing this side investigation that ended up in the chart, you know? That question doesn't need an answer here, but it is the kind of questioning that one could worry about if they were interested in protecting their license. Always take good care of the patient first. I trust you did that, but then make sure your documentation leaves no question about it.

And thank you for being open to hearing critique. It is meant in the spirit of help for you and patients.

Cdonocdo

Has 7 years experience.

@Wuzzie Thank you for your response. The policy at our facility for narcan administration is the following: Prior to administration: • Assess for respiratory dysfunction/ depression (character, rhythm, and rate of less than 10 breaths/minute.) • Assess for LOC and pain before and after administration. 

 

How could I better support the intervention in my documentation? I'm not being a smartass, I'm just curious and want to know what other documentation I should include- so next time I'm better prepared. Thank you!

Cdonocdo

Has 7 years experience.

@JKL33 I appreciate all feedback, both negative and positive. Thank you for taking the time to respond to me. I love how nurses can all learn from each other 🙂 

1 minute ago, ceileann said:

both negative and positive.

It's all positive. 😉 Seriously.

I'm not going to nitpick; with the above recommendations (bolded removals for next time around), it's good documentation of a very acute situation in a setting not meant to be equipped to fully assess or fix the patient's problem(s). You all did the right things.  And got him to the next level of care. 👍🏽

15 minutes ago, ceileann said:

How could I better support the intervention in my documentation? I'm not being a smartass, I'm just curious and want to know what other documentation I should include- so next time I'm better prepared. Thank you!

Clearly the guy was in distress and you did a proper assessment but other than slightly decreased respirations nothing else supported a narcotic overdose which, in the end, he wasn’t actually suffering from. So there’s really nothing you can change to support the use of Narcan. It was a good thought, of course, and it wouldn’t have hurt him but in these kind of situations you can’t focus on just one possibility. I don’t know how long you’ve been a nurse so I’m hesitant to go into teacher mode and risk upsetting you. 

Cdonocdo

Has 7 years experience.

@Wuzzie You're not going to upset me at all, I've been a nurse 10 years but I'm willing to learn. They did end up doing narcan x 4 once he got to the ER, the hospitalist note stated primary issue opioid overdose and secondary issue afib. 

FolksBtrippin, BSN, RN

Specializes in Psychiatry, Pediatrics, Public Health.

The most striking assessment piece that doesn't fit opioid overdose is the dilated and fixed pupils.

You should see constricted pupils with opioid overdose.