charting meds dur conscious sedation for another rn

Nurses Medications

Published

don't know what to do...i am being asked to chart on another nurses patients everything that the other nurse does so the other nurse would be available to monitor the patient at the head of the bed without interruption during conscious sedation...vital signs and the medication that they push...the direct care nurse transcribe it on a medication form but our facility wants us to enter that information for that other nurse...just not comfortable with that request....

Specializes in CVICU.

In my experience if I'm charting what another nurse is doing I state in my charting "J. Doe, RN applying manual pressure to right groin" during a sheath pull. I would imagine its the same way charting meds on a flow sheet. " 1mg versed iv push administered by J.Doe,RN at 2145"

I'd ask other nurses or your manager what is expected for this type of documentation if you're still uncomfortable.

Specializes in Trauma Surgical ICU.

Basically you are being used as a scribe nurse. You are there to chart what is done at what time and how the pt is responding ie: vitals. There is nothing wrong with this. In the ED or OR this is done all the time to cover what is being done and when. Previous poster is right with her examples of charting what the administering RN has done.

I have done this a few times during procedures. For our cardiovert flowsheet it has a place for the scribe nurse to sign, the administering nurse and MD to sign afterwards. Same thing for our code flowsheets..

Are you on electronic MARs? Most have an option to where you can chart a med given and then chart who it was that gave it.

so more details of my fear is...the sedating nurse at the head of the patient bed is pushing meds and charting their own meds manually on a form signed by the physician....and i am charting the meds that that nurse told me they just pushed in the electronic chart....question....what if that nurse is pushing the limits on the level of consciousness....to needing an anesthes. am i charting that i agree with the other nurses work? eeven if i don't agree with how much med given to the patient

Specializes in Pediatrics, Emergency, Trauma.

During conscious sedation there are parameters and most, if not all of the drugs are weight based. If everyone is using the time-out and specific methods a previous poster stated, this is the norm.

If you are uncomfortable with recording, I suggest you get to know your facility's policy regarding conscious sedation, and familiarize what is being given, concentration, etc.

Understand that a scribe in the procedure room is acceptable thanks for the input.... i am expected to also have a dual role for retrieving, opening and handing off sterile devices to the scrubbed in RT...i am extra help in this room every 6 to 7 weeks and am not knowledgable about where to find the supplies needed during a case...the RT has to step away from the table to point to the catheter or wire that is needed...just doesn't sound right....

Specializes in PACU, OR.

There are times when a second person doing the charting is, if not essential, at least extremely useful in ensuring that correct times of administration are recorded and also in recording events, such as adverse reactions. A circulating nurse assisting an anaesthesia provider does much the same thing. Nothing to be worried about.

If you are concerned, you can ask the nurse you are assisting to co-sign with you at the end of the procedure, thus accepting responsibility for what was administered. She is supposed to display what she administers when she draws it up, anyway. Just be alert.

Specializes in Trauma Surgical ICU.
Understand that a scribe in the procedure room is acceptable thanks for the input.... i am expected to also have a dual role for retrieving, opening and handing off sterile devices to the scrubbed in RT...i am extra help in this room every 6 to 7 weeks and am not knowledgable about where to find the supplies needed during a case...the RT has to step away from the table to point to the catheter or wire that is needed...just doesn't sound right....

You are learning a new role, it will take time to know the supplies,location etc

+ Add a Comment