Charting question

[MissyF_RN]

i work on a busy mud surg floor. a few weeks ago i had a patient ask for pain medication during my assessment. she had no prn pain med ordered (new admit from 1500).

in my 1930 pain assessment (in our hospital we use the meditec system) i charted her pain and under comments wrote "no medication ordered. will notify md". i called the doctor and received an order for toradol at 1940.

pharmacy did not send me the medication until 2050. i gave the patient the medication at that time and did chart another pain assessment and commented that i gave the medication and to see the mar.

at 2130 i made another pain assessment that the medication helped and the patient was resting quietly with no signs of pain noted. she happened to be sleeping.

here's my question. her chart was audited and my supervisor said i should have made an actual nurses note that i had called the doctor about the pain medication. i did tell her that i did chart the pain and that i had notified the doctor in the pain assessment. my charge nurse said how i charted was fine. i don't see any problems with the way i charted it. any opinions?

[classicdame, MSN, EdD]

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.

[loriangel14, RN]

Yeah sometimes what/how to chart is pretty subjective.We use Meditech where I work as well.I guess you could have entered a focus note regarding the c/o pain and the unavailability of a pain med but I wouldn't worry about it too much. You charfed your assessment and noted you had called the doctor.I would say that was adequate.

[RNperdiem, RN]

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.

[pers]

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.

[caeRn]

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!!!

[rn/writer, RN]

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.

[Orca, ADN, ASN, RN]

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.

[LilgirlRN, ADN, RN]

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.

[jorjaRN]

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.

[scoochy]

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."

[PAROPPY, BSN, RN]

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.