Cath lab documentation......

Published

been a ccu nurse for over 8 years and recently started in the cath lab. my only concern is that we have cvt's, arrt's and one emt doing the documentation in the mac lab and nurse signs the report. there are some portions of the report that require nursing dx and other nursing documentation that "techs" are filling out. my question is, is it the norm for a cvt or arrt to be doing the actual documentation in the mac lab and the nurse signing it off.

Up Vote Up Vote ×

The lab I work with doesn't have nsg diagnoses in MacLab so I'm curious where and how nursing diagnoses were worked into your Mac Lab. Are they part of custom-built macros? Forms? It also sounds like your lab has a nurse sign off on the report after the case is finished. Do they sign-off after sections that are specifically nursing-related or are they signing off on the full report?

I, too, am concerned about using Mac Lab and still be able to identify exactly who was responsible for what, as well as non-nurses doing clinical documentation that in other cases would be restricted to licensed nurses only. If anyone else has a better grasp on what are and aren't appropriate documentation methods in a system like MacLab, I'm interested to learn more.

Thanks, OP, for asking the question!

Up Vote Up Vote ×

My understanding is that, its part of a custom form in the mac lab that has to be turned "on". Yes, a nurse has to sign the report, plus the physician and monitor tech. The nurse is signing off the meds that nurse gave, basically its our MAR. My thing is that a cvt or even a arrt is filling out nursing documentation ie pulses,nursing dx, iv site..... Lets be realistic here, the "circulating nurse/in the room" is not going to read 16-20 pages of documentation. To be honest I only look at the medication section. I've brought it up the the cath manager(is not even a nurse, arrt or cvt but thats a whole another topic) and has no clue what the nurse is really responsible for. So if anyone can chime in. tia

Up Vote Up Vote ×
Specializes in Cardiac.

If you will consider/communicate to the monitoring person as a scribe for any/all documentation you would normally perform, I don't see the issue. Is it that a non RN is doing the actual assessment, or that they are putting that information in? MacLab automatically performs vitals and asks for LOC. MacLab also captures hemodynamic data and equipment data.

The reports can be split so that nursing can get what is relevant-but there is so much more going on. For instance, is ACC/NCDR information being captured during the procedure? Does your system also control inventory/billing/standardized reporting? Is this information scrolled automatically to an IT system?

Anything that you would normally document can be added at any time-communicate and educate non RN personnel as to what is needed in the chart (ie pain/intervention, procedure response, complications, comorbities that can affect the patient/etc).

Hope this helps...

Up Vote Up Vote ×

bump! It's been awhile. Anyone have anything to add here? Thx!

Up Vote Up Vote ×
Specializes in Cath Lab, ICU's, Pediatric Critical Care.

I'm working in a lab now that has 1 RN and 2 rad techs on a team. That means that the RN circulates, 1 RT scrubs at the table, and the other monitors.

At my previous jobs, the teams could have 2 RN's and 1 RT. So we often could have an RN documenting. The person on the monitor charted everything, including meds/treatment/patient changes, etc... the RN would call out.

All staff, including the RT's, at my previous jobs, did an outstanding job with documentation.

Current: the RN's chart their meds and anything they feel is pertinent (i.e. change in patient status, O2, notifying the MD about something, etc)... I find I document as much as I can, and be as thorough as I can. The RT's will only chart items pertinent to their job! Some don't keep an eye on the monitor like they should, some are not focused, some don't even care/know how to properly put on a BP cuff! When the doc is done with the chart, and it's sitting in the control room...guess who has to go get it???

Don't mean to gripe....but I see changes that need to be done, and it goes nowhere....

Up Vote Up Vote ×
+ Join the Discussion