Asked To Change My Nursing Note...

[spotangel, DNP, RN, NP]

Lots of good advice. Take it to heart.

Rule of thumb when charting. Don't ever implicate the facility. Defense lawyers will have a field day if it ever goes to court. Don't write incident report/MIDAS filled in your clinical note as then those can be requested by lawyers based on your documentation. Keep it short and sweet.I took a class with NYS Prosecutors about documentation in the medical chart as part of a Sexual Assault Forensic Examiner (SAFE)class. It was excellent!

Your note

"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."

 My note

Informed by CNA X of acute change of status. Pt found in chair pale, diaphoretic,convulsive and tremulous, with RR irregular and shallow 8-10/min. Pt safely transferred to bed by pt's RN Soto and writer and safety precautions maintained. Vitals BP,Pulse, sat, finger stick glucose. Last dose of dilaudid for low back pain given @ 8am. PRN Narcan not available. EMS called at 8.15 am,  ACLS team arrived at 8.25 am and transported pt to hosp Y  ED@ 8.35am. DON Curt Boss informed. Pt's wife Sandra informed. Dr Stay at home informed.

Late note @ 3pm report given to oncoming supervisor Curious Mary.

I would still do an internal incident report about the missing Narcan and follow up with the DON about need for communication in a written email. This will prevent you being thrown under the bus and protect your license in case the pt gets sicker and there is an investigation.

At this time I would not change my note. Even though there was lack of communication from the DON's side. Tell her I wrote what transpired and wish that it was communicated to me ahead of time that the narcan was removed. That is a safety issue. Moving forward, I will put those issues in the internal incident report.Be sweet but firm! All luck!

[Sour Lemon]

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.

[JKL33]

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.

[JKL33]

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.

[Wuzzie]

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. 

[JKL33]

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.

[Wuzzie]

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. 

[Emergent, RN]

I think that if your boss had sent a less confrontational email, that you wouldn't have gotten your hackles up. I know I wouldn't have liked being approached that way. It's just not very productive.

All of the above advice was superb. Maybe there will be an opportunity come up for you to let your boss know that you tend to be more receptive to feedback that is given in a collaborative and respectful manner. 

[Kooky Korky, BSN, RN]

On 2/22/2021 at 7:18 PM, 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.  

The answer to your question lies within your own statement here.

You were infuriated.  This emotion does NOT belong in the patient's chart.

I don't know if you should change your charting if the original will still be visible but you must never chart your fury in the charts ever again.

You should probably start looking for a new job.

I am not saying you were wrong to be upset but you were wrong to chart it.

What is an SDC?

Do some educating on proper dosing of Dilaudid.

Best wishes.

[Kooky Korky, BSN, RN]

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.

Way too much but don't change it again, methinks

Just say, in the future pt difficult to arouse, resp 8 per minute, and chart the other VS;

Narcan not available; EMS notified; pt transported to ______; wife and Dr. whoever notified at (time);

Later, after you know he was admitted, make a 2nd note to state that.  You could, I suppose, say he also had a fib but why?  It is irrelevant with regard to the Dilaudid overdose.

[Kooky Korky, BSN, RN]

On 2/22/2021 at 7:36 PM, ceileann said:

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 think IR's also get reviewed by Admin.

Learn to be much less wordy in general.  And your statement about this nurse and that nurse and Supervisor makes it sound like 3 nurses were involved.  I think it was only you and the floor nurse right?

On 2/22/2021 at 7:35 PM, Wuzzie said:

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

BS collected by?  Who cares for purposes of this situation?  And was anything done about it anyway?  Or just say FSBS 263.  

Why is it necessary to say the CNA did this, the pt was in his chair, the nurse collected whatever?  Just too much irrelevant detail.

And why isn't his nurse charting?  Why do you, as Sup, have to chart anything?  Unless you were just helping the nurse maybe?  Or your employer requires you to write a note?

And when he gets back to your facility I would really have to wonder what can be done to really get him some relief of back pain because the stimulator seems to be ineffective.  How long has he had it?  Has it ever enabled him to be off of heavy duty meds like Dilaudid?

Things like heat, cold, exercises, massage, positioning, TENS, etc. might need to be explored again, assuming they have already been.   A lot of people with stimulators seem to not get much relief and wind up getting them removed.

[NRSKarenRN, BSN, RN]

Colleagues have offered great advice re charting PERTIENT info only--- too much can run you into legal jeopardy been my experience.    Objective details of narcan  not in facility belong in incident report, which SHOULD be reviewed at a Admin mtg including Administrator, ADON, DON -Quality improvement if SNF has that position too. Staff need to be educated ASAP  re ekits removal what to do to obtain meds from new pharmacy.

SDC = staff development coordinator /  ADON= Assistant Director of Nursing --  nurses in those positions usually have access rights to all charts in a facility.