Charting question

if she questioned it someone else might. The point is to make it clear that the MD was called, as opposed to "intended to call". Thank goodness you charted the effect of the intervention! Consider how it would look if the patient again requested pain meds and there was no evidence you had followed thru the first time. Good for you.

Picky.

The doctor ordered the pain med. The patient got the relief they needed. Shouldn't that be enough for an audit?

I'll make a point to chart in the notes about doctors being called for more serious matters.

We have to do a patient note every time we call the doctor about anything even if the doctor doesn't give us any new orders.

Even if you think auditors are being picky you need to chart it. In the end if the audits are not approved your hospital wont get paid and if they dont get paid, guess who will suffer in the end? You because they will be losing money they could use for merit raises etc. You gotta look at the BIG picture!!!

I would chart calling the doc to show that you did it and to document the time it was done. This is especially important if it takes a lengthy time for the doc to return a page. If you have to call again, document that as well. This kind of record shows that you were diligent and attributes any delay to the person responsible. After all, you can give meds that weren't ordered.

My questions is why the doc who admitted your patient didn't order something for pain in the first place. That seems like a pretty basic need.

Addendum: The bolded sentence should read, "You can't give meds that weren't ordered." Or more correctly, "You shouldn't give meds that weren't ordered." Oops.

I charted her pain and under comments wrote "no medication ordered. will notify MD".

Nothing in this passage says that the doctor was actually called. It says that at the time you wrote the note that your intention was to call, but nothing to show that you actually followed up on your intention.

I would chart calling the doc to show that you did it and to document the time it was done. This is especially important if it takes a lengthy time for the doc to return a page. If you have to call again, document that as well.

I have done this as well. That way, if anyone should question why your patient complained of pain and you didn't medicate him/her until three hours later, you can show that it wasn't inattention or a lack of effort that caused the delay.

I always note when I've called the doc about anything especially pain and note if I received an order to do anything. I always chart anything I can do to make the pt comfy such as repositioning, ice, elevation etc. I work in teh ER so our tsheets kinda prompt us. If I give pain medication there is a box to check underneath it to say if there is an improvement or not.

We use meditech at my hospital too. do you have the "notify physician" intervention available to you? I chart under that for every time I call a doctor, and it asks who you spoke to, why, and whether you received any new orders. It's pretty easy to use, and that way you don't have to create a whole nursing note. I guess I might mention it in my end of shift note too, but maybe not.

I make a point to always chart under that intervention, even when there were no new orders because it protects me to some extent by showing that the MD was made aware of changes/issues.

I would chart calling the doc to show that you did it and to document the time it was done. This is especially important if it takes a lengthy time for the doc to return a page. If you have to call again, document that as well. This kind of record shows that you were diligent and attributes any delay to the person responsible. After all, you can give meds that weren't ordered.

My questions is why the doc who admitted your patient didn't order something for pain in the first place. That seems like a pretty basic need.

I believe you meant "...you can't give meds that weren't ordered."

Even though you didn't write anything specific about calling the doctor, the pain med obviously got ordered and was given because you documented pain relief in your note. But now you know for the future.

I believe you meant "...you can't give meds that weren't ordered."

Scoochy, I think what she meant is that it is technically possible to give meds that weren't ordered. I could go to the Omni in my ER, take out morphine that wasn't ordered, and give it to my patient. There's nothing to prevent me from actually doing that except for the fact that I might lose my license, so it IS possible. Because of this fact, it is important to chart that the Dr. was notified and orders were received, in addition to charting that meds were given and a pain assessment was done.