charting MD aware when you were not the one responsible to call MD as per facility policy

[Yoyo1313]

I recently took a night shift RN position in a ltc facility. Per the policy at facility I notify RNS of any issues and the RNS is responsible to call MD yet they want me to document MD aware. It makes me feel really uncomfortable and I think of legalities. Any insight would be great since its facility policy yet I believe its not my responsibility to chart MD aware since I never called them. I also feel its incomplete documentation since I write MD aware but just leave it at that nothing follows because I don't get any new orders or any instruction since I never called MD the supervisor is supposed to...so I feel the supervisor should chart it then.

[tyvin, BSN, RN]

Chart that you have handed off to the next shift that they have been told to notify such and such for such and such purpose. Than include that in your report. Be sure to chart which shift...putting a name of a nurse is usually not a good idea since it could turn out to be someone else who does the actual phone call.

Now this is reserved for such things that are not emergent like you discovered a patient hadn't been taking a certain med for a few days (vitamins, Colace, etc...), that you're recommending a wound change or status of wound, or to clarify an order, etc..., things like that. If it's anywhere near emergent; call the doc no matter what time it is.

You can't chart something you haven't done period; no matter who tells you to do it. This goes for any shift. Nursing is a 24 hour job and many things from night are handed down to day shift simply due to the time of day.

[Glycerine82, LPN]

How do you know Saly, RN really did notify MD? Why isn't OP just doing it herself? I'm thinking OP isn't a nurse?

Ah ha! OK. So, what about "per protocol notified sally, RN, to call MD" ?

Truly just curious. I feel like if I were the OP, and a(n) RN, I would call the MD myself, since she's supposed to "Tell the RN", can't she just tell herself?

Again, forgive me, I'm trying to suck up as much knowledge as possible ;-)

[tyvin, BSN, RN]

OK guys, you're making this more complicated than it is...

But first, let us know what type of charting your facility requires the nurses to use...or do they; than we can help you accordingly:bookworm:

[CapeCodMermaid, RN]

Why does one RN have to tell another RN to call the doctor? When I was a staff nurse, I'd call the docs myself. I wouldn't rely on a supervisor to do it for me. If the doc needs to be called in the middle of the night, you'd darn well better call him. If the doc gets angry, shame on him.

[Spidey's mom, ADN, BSN, RN]

Why does one RN have to tell another RN to call the doctor? When I was a staff nurse, I'd call the docs myself. I wouldn't rely on a supervisor to do it for me. If the doc needs to be called in the middle of the night, you'd darn well better call him. If the doc gets angry, shame on him.

I agree with this. The nurse has firsthand knowledge of what is going on and can answer questions the doc might have (VS, lab results, A/O, etc.). Passing that on to another person who isn't caring for the patient leaves a large hole in knowledge to be passed on. Plus, ever play the Telephone Game? Second-hand info is usually not very reliable.

Do not chart something you did not do - basic Nursing School knowledge.

[mariebailey, MSN, RN]

I like Glycerine82's line of thinking, documenting something like, "Per facility protocol, notified Amy, RN Supervisor, of change in patient status". I would also document any follow-up with the RNS showing that you ensured timely communication & promptly implemented any new orders. It would be accurate documentation that she intervened appropriately according to her facility's protocol.

[MunoRN, RN]

There is absolutely nothing wrong with charting "MD aware per report of Sally RN".

It's also incorrect to claim RN's never chart something we didn't personally do, we chart things we didn't personally do all the time. For instance, if I come on and the labs from the previous shift have resulted, I might include in my note that I'm transfusing a unit for an H&H of 5/16, even though I'm not the one who drew that H&H nor did I run the lab. I might say we're starting antibiotics because the patient's echo showed endocarditis even though I didn't perform the echo or interpret it. So long as the charting doesn't confuse you as having done something there's no reason to intentionally leave out some piece of communication.

[Loo17]

That sounds a little weird. Maybe you could chart MD notified by supervisor per facility protocol, no new orders at this time.

[tyvin, BSN, RN]

This person is on nights...the docs offices are not open at 07:00 when they go off or give report.

[tyvin, BSN, RN]

There is absolutely nothing wrong with charting "MD aware per report of Sally RN".

It's also incorrect to claim RN's never chart something we didn't personally do, we chart things we didn't personally do all the time. For instance, if I come on and the labs from the previous shift have resulted, I might include in my note that I'm transfusing a unit for an H&H of 5/16, even though I'm not the one who drew that H&H nor did I run the lab. I might say we're starting antibiotics because the patient's echo showed endocarditis even though I didn't perform the echo or interpret it. So long as the charting doesn't confuse you as having done something there's no reason to intentionally leave out some piece of communication.

Really ...

[BuckyBadgerRN, ASN, RN]

This person is on nights...the docs offices are not open at 07:00 when they go off or give report.

SOMEONE is on call for the group, you can bet there is a Dr SOMEWHERE prepared to take any needed calls

[CapeCodMermaid, RN]

May I assume RNS=RN Supervisor? Never saw that before.