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Charting a case you weren't there for


Last week one of our surgeons did an emergency colonoscopy for a GI bleed in the CCU. It was late and the call nurse was already working on a load of ortho cases that had been on all day. The surgeon went ahead with the procedure having the endo techs to assist, and the CCU nurse push the conscious sedation.

Yesterday, my supervisor brought to me a bunch of hand written notes from one of the endoscopy techs regarding the case and asked me to chart the case. The information has case staff, times, medications given at what time, and the patient's blood pressure q 5 minutes.

I am very displeased with being asked to chart a case that I was not present for. I am concerned that there may be legal issues by charting this information as if I had been there. My supervisor stated to just write a narrative noted stating that I was not present in the case, and that I was only charting the information to allow the hospital to charge for the procedure. With the chart being a legal document, could I be called to court later because I charted the information? In endo cases we are supposed to chart vitals q 5 minutes, but the only thing I have is the patient's BP. No pulse, no respiration rate, no sats.

I just don't want to be called to the carpet in the future for something I was not a part of.

Thanks in advance for the help.

icuRNmaggie, BSN, RN

Specializes in MICU, SICU, CICU. Has 24 years experience.

That is ridiculous. I have worked endo. I would not complete the charting if I was not present. If something was perforated or even a infiltrated IV occured or a delayed transfusion reaction you will be liable. Frankly it sounds fishy. The manager needs to do that himself with a sentence that reads

" refer to concious sedation documentation by JBrown RN ICU Staff"

If this is a military facilty remember that the Uniform Code of Military justice says that you do not have to follow an unlawful order.

Edited by icuRNmaggie

Rose_Queen, BSN, MSN, RN

Specializes in OR, education. Has 15 years experience.

I would never document for something I was not there for at all. I have documented in emergency chest traumas where I arrived in the OR after the patient, but I was assuming care of the patient from the in house OR nurse- which to me is a totally different situation than documenting on a patient I never took report on or assumed care. If your manager is so concerned about charging, why doesn't he do the documentation?