Asked To Change My Nursing Note...

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 

Specializes in ED, Tele, MedSurg, ADN, Outpatient, LTC, Peds.

Is the DON trying to protect herself? I would be looking elsewhere to go. Does not look like someone who has your back at all. That’s illegal.

My email trail would continue—- about the incident report  that is “found “in the shredder—— while I look out for another job!

Next time Don’t change your note. It puts You in a bad light in case of an investigation 

Specializes in Physiology, CM, consulting, nsg edu, LNC, COB.

Did I miss something? If you have an electronic health record, any changes will be apparent in the metadata, including who (and when) accessed that note, altered it, or erased it, even if it looks like you erased them and rewrote them. If there were ever any investigation, it’ll all be there for the finding. 

If you have paper/handwritten documentation, standard of practice is to draw a single line  through it, with a note that says, “see revised note on date, YourName.” NEVER remove a written page and replace it.

As for the incident report, if they told you never to mention it in a nursing note because then it will be fodder for investigation, believe me when I tell you that every atty that does cases r/t hospitals knows perfectly well there is one, or the atty’s legal nurse consultant does. There are ways ...

And the shredder box? As soon as you have secured your next job, which you will pursue stat, report to the BON and the state agency responsible for the facility license or accreditation.

Specializes in retired LTC.

It had always been my understanding that incidents reports were considered 'in-house' documents. And as such, it is up to each facility how to process the info presented. Once the incident has been reviewed, investigated and documented, and determinations made for remediation, the facility was free to dispose of in-house documents however it pleased.

Nothing I ever knew specified that there was some regulation requiring to maintaining incident reports for some spec length of time. Only that an investigation was mandatorily conducted.

So, it could be that the DON did do her end of the investigation and shredded the IR. (Altho, I do agree, that this might have been a bit PREMATURE. And considering some type of cover-up as possible.)

OP - I think there's fault with the DON's "failure to communicate" critical info that resulted in this critical occurrence. And that's the root issue here being  very damning for the DON's and facility's liability should more come about in this case.

Your orig info 'will live into perpetuity'. Consider a new job. I don't know I reporting this whole episode to your DOH will help as you will likely become ensnared into it. Report it up thru Corporate if poss.

Good luck to you.

I agree with all of the suggestions but you need to realize that as a supervisor and nurse that your actions are open to not just medical interpretation but also legal. You should always chart with that in mind. Make the briefest possible notes with the relevant information and be non judgemental. 

There are always remits from different disciplines that are different from your own. You work as a team and you have now made yourself a target possibly. 

If you can get away with being invisible, that's always the way to go. Increased visibility means increased accountability!

No offense intended, but a lot of nurses doesn't appear to know the scope of their duties or how to work within the framework of limiting their liability. Always allow the Drs orders and institution's instructions to cover your posterior. Just my opinion. 

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! 

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. 

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. 

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. 

@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!

@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 ? 

+ Join the Discussion