Asked To Change My Nursing Note...

Nurses General Nursing Nursing Q/A

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 

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. ??

@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. 

Specializes in Psychiatry, Community, Nurse Manager, hospice.

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. 

ceileann said:

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. 

If you get the chance to give a basic update when he gets back, I'd be interested to hear it.

ceileann said:

@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. 

How did you become privy to the ER documentation?

@Wuzzie three nurses were involved. It was myself, the patients nurse and the weekend supervisor. I’m glad I was able to get that across. 
 

@Been there,done that I have access to their documentation system for looking at progress and screening for readmissions. 
 

I’m ending this thread, I totally appreciate the responses. I was looking for constructive criticism and thank you for feedback. Yes being more concise in notes would be ideal but our facility does not have a chart by exception policy. It’s 100% free text so I have to include all vitals etc. I’m going to use something I learned from one of the comments regarding some of the latter comments- I believe the feedback could have been conveyed in a much constructive and respectful manner ?. 

I didn’t ask about who was involved. That was another poster. 

ceileann said:

@Wuzzie three nurses were involved. It was myself, the patients nurse and the weekend supervisor. I'm glad I was able to get that across. 

@Been there,done that I have access to their documentation system for looking at progress and screening for readmissions. 

I'm ending this thread, I totally appreciate the responses. I was looking for constructive criticism and thank you for feedback. Yes being more concise in notes would be ideal but our facility does not have a chart by exception policy. It's 100% free text so I have to include all vitals etc. I'm going to use something I learned from one of the comments regarding some of the latter comments- I believe the feedback could have been conveyed in a much constructive and respectful manner

HIPAA does not allow anyone to access medical records, unless they need to know. You WANTED to know. I hope this does not become another problem for you.

Peace

@NRSKarenRN thank you. On a personal and professional level, I felt blindsided because as the SDC- I couldn’t even educate the staff or alert them about the kits being taken off the floor. We hadn’t started with the new pharmacy yet, they take over the first off the month. The kit really shouldn’t have been removed. 

@Been there,done that yes I did want to know- because I had to screen him for readmission. I am allowed to access charts to review prior to admission. Not a violation. 

Specializes in retired LTC.
53 minutes ago, spotangel said:

... Don't write incident report/MIDAS filled in your clinical note as then those can be requested by lawyers based on your documentation.  .!

This has always surprised me in that just about everyone knows that an incident report WILL BE generated, usually because facility P&P will require it. So if everyone already knows that there prob is one, what are we trying to be soooo secret about? What are we trying to hide?

State surveyors expect incident reports for significant episodes occurrencesas part of in-house investigations. So I'm sure lawyers know they're avail also. So they can be requested and subpoenaed, if nec.

Am a little off topic -

I would never change a nursing note.  It admin doesn’t like it maybe they should be better at their jobs.

Specializes in ED, Tele, MedSurg, ADN, Outpatient, LTC, Peds.
2 hours ago, amoLucia said:

This has always surprised me in that just about everyone knows that an incident report WILL BE generated, usually because facility P&P will require it. So if everyone already knows that there prob is one, what are we trying to be soooo secret about? What are we trying to hide?

State surveyors expect incident reports for significant episodes occurrencesas part of in-house investigations. So I'm sure lawyers know they're avail also. So they can be requested and subpoenaed, if nec.

Am a little off topic -

Good question! The answer I was given is  that internal investigation don’t have to be shared with law enforcement or lawyers. I think it is more in lieu of protecting the institution and staff if the mistake was on our part.

 I don’t  know enough about sharing of incident reports with surveyors. If it is a NYPORT( The New York Patient Occurrence Report and Tracking) which is a mandatory adverse event system report it can be requested online. 

+ Add a Comment