Charting physician contacts..

[ccer99]

New nurse here with a question about appropriate charting.

1. When you guys/ladies contact a physician, do you chart their response word for word in quotes? For example, I contacted a physician the other night because my patients SBP Was in the 190'S. I administered the prn meds I had available (apresoline for SBP Above 160 And Trandate for SBP above 190) without adequate results. When I called and explained situation I was told ,"I don't have time for this, I'll deal with it later" and was hung up on. I was told to chart this response word for word, as opposed to charting what I told the doc and that there were no new orders recieved. What is most appropriate to chart?

2. I recieved a patient the other night and their central line dressing was half off and saturated, vent tubing hadn't been changed in 3 days, Ativan gtt hanging for almost 36 hours, Foley care had clearly not been done in days...do you chart a nurses note that you recieved the patient that way?

Thanks for the input!

[Nalon1 RN/EMT-P, BSN, RN]

Write word for word what the physician said. This needs to be addressed at an administration level and having the exact words said will help them correct this.

For the other pt, document in nurses notes how the patient was received, but not blaming anyone, more just a CYA, just how you found them. Then document you care as normal for what you did to correct it. Report it to at least your charge nurse, if not higher. That patient is at severe risk for CLABSI, CAUTI, and/or nosocomial pneumonia.

[vintagemother, BSN, CNA, LVN, RN]

I'm a new nurse, so I may not be aware of the best way to handle this, but I think that we shouldn't state things derogatory about another staff person in the pt chart.

I'm thinking that you create an internal paper trail, like an incident report or something similar about the MD, but in the pts chart, you write, "MD notified. No new orders received."

I, personally, do not use the pts chart to illustrate a lack of proper care for a pt.

The only way I'd do this is if the facility was trying to set me up, and refused to address the problem, and the problem impacted my ability to provide pt care.

I'm an LVN, so I have been in positions like the ones you described.

I'm in RN school now and some professors say we should chart about staff who don't provide good pt care and others who said we shouldn't.

This week, in school, the professor gave an example of when an EMT threw an MD "under the bus", so to speak, in front of the pt.

There was a bad outcome for the pt and everyone was sued: the MD, the EMT, the hospital, the nurses.

In the end, proper charting saved the accused MD and hospital and the EMTs poor charting made him appear more liable.

If he wouldn't have said anything negative about the pts tx, the law suit may not have been filed.

Just my opinion....

[Nalon1 RN/EMT-P, BSN, RN]

It is not derogatory to quote what someone says that affects patient care. You are only documenting what was said.

Which looks better:

"MD notified. No new orders received"

or:

"MD contacted regarding continuing hypertension after all PRN HTN meds given with no change. MD states "I don't have time for this, I'll deal with it later" and hung up, unable to obtain further orders".

If the patient strokes out a hour after the phone call, which would you want to have on your charting? Which one really shows what you as a nurse are trying to do for your patient. If you want to say that the second one throws the MD "under the bus", well, it does, but only because you quoted what was said. Doctors need to be accountable for their actions. I have enough responsibility, I am not taking theirs also.

On the other hand, you would not chart "I called the doctor and he yelled at me and refused to give me any orders then hung up". The doctor can say that he did not yell and that he was going to call back or he got disconnected or whatever. If your charting is consistent and you always chart exactly what was said you have a lot more credibility.

Now all that being said you should still try to get the issue resolved, just saying "well I called the Dr and he did nothing" does not clear you. Every facility has a different process for this. Follow the chain of command.

For the second one, your not assigning blame, your documenting how the patient was received, regardless of if it is a new admit or from another nurse on the shift before. Most of this can be documented in your assessment, but with computer charting, some things are not able to be done except in a nurses note.

Your not charting bad about other people, your charting what you find and how you find it. Not that "so and so did/did not do this or that".

Do you want to be the one that was blamed for something that someone before you did/did not do because you did not want to chart it and "assign blame"?

[OBwonKnewbie]

It is not derogatory to quote what someone says that affects patient care. You are only documenting what was said.

Which looks better:

"MD notified. No new orders received"

or:

"MD contacted regarding continuing hypertension after all PRN HTN meds given with no change. MD states "I don't have time for this, I'll deal with it later" and hung up, unable to obtain further orders".

If the patient strokes out a hour after the phone call, which would you want to have on your charting? Which one really shows what you as a nurse are trying to do for your patient. If you want to say that the second one throws the MD "under the bus", well, it does, but only because you quoted what was said. Doctors need to be accountable for their actions. I have enough responsibility, I am not taking theirs also.

On the other hand, you would not chart "I called the doctor and he yelled at me and refused to give me any orders then hung up". The doctor can say that he did not yell and that he was going to call back or he got disconnected or whatever. If your charting is consistent and you always chart exactly what was said you have a lot more credibility.

Now all that being said you should still try to get the issue resolved, just saying "well I called the Dr and he did nothing" does not clear you. Every facility has a different process for this. Follow the chain of command.

For the second one, your not assigning blame, your documenting how the patient was received, regardless of if it is a new admit or from another nurse on the shift before. Most of this can be documented in your assessment, but with computer charting, some things are not able to be done except in a nurses note.

Your not charting bad about other people, your charting what you find and how you find it. Not that "so and so did/did not do this or that".

Do you want to be the one that was blamed for something that someone before you did/did not do because you did not want to chart it and "assign blame"?

I absolutely second following the chain of command since you did not get what you needed from the first doc.

[ccer99]

Thanks for the input :) I did follow chain of command and get the orders my patient needed so no worries there. I was just unsure of what I should have put in my charting.

[Karou]

We have had this issue in the past. What's been told by the powers that be is that it is "not professional" to chart negative things about coworkers/physicians in a patients chart.

We would instead be told to chart "Dr. Lastname notified of patients blood pressure being xxx, PRN anti hypertensives administered and not effective, no new orders received".

THEN do an incident report/internal documentation for the physicians rude behavior, where you include the word for word response.

Same for receiving a hot mess of a patient. Incident report. I would include in the flow sheet anything pertinent/applicable though, like dressings were soiled and hanged and tubing changed, ect...

[Cola89]

It's not that I wouldn't address the issues, I just wouldn't address them in the patients' charts. You can put what someone said in quotations all you want, but it's still your word against theirs as to what actually was said. I would do my job, cover my ass by writing "dr. notified. no new orders received." and leave it at that. You were right to call another provider if actual time/attention/orders were needed.

Another thing as in when you receive a patient say for example like I did- received a patient from a hospital into a nursing home setting. The previous nurse even called to say 'oops, fyi i forgot to take out xyz's IV(!)'. I said "no problem, I'll take it out." Didn't chart about that. Just did it. I know receiving patients who are dirty, etc is a bit different, but you should chart on them objectively. Not they look like they haven't had a bath in days!!

[Greenclip]

We have had this issue in the past. What's been told by the powers that be is that it is "not professional" to chart negative things about coworkers/physicians in a patients chart.

We would instead be told to chart "Dr. Lastname notified of patients blood pressure being xxx, PRN anti hypertensives administered and not effective, no new orders received".

THEN do an incident report/internal documentation for the physicians rude behavior, where you include the word for word response.

Same for receiving a hot mess of a patient. Incident report. I would include in the flow sheet anything pertinent/applicable though, like dressings were soiled and hanged and tubing changed, ect...

I second what Karou said.