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?

[GM2RN]

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.

[rn/writer, RN]

After all, you can give meds that weren't ordered.

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

Yup, that's what I meant. Thanks.

[rn/writer, RN]

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.

Nah, I just goofed. But you are correct in what you are saying. It is technically possible to give meds that were not ordered but it certainly isn't advisable to do so. Charting your communication with the doc is a good way to show when and how the orders were received.

Thanks.

[bill4745, RN]

You stated that you would notify the MD, the verbal order indicates that you did.

[rn/writer, RN]

You stated that you would notify the MD, the verbal order indicates that you did.

But it doesn't cover her if there are hours between stating the intention to notify the doc and the actual giving of the med. Maybe it's overkill if only a short time elapses and it's obvious what happened, but if I page a doc and it takes more than a half hour to get a response, I document that I paged the first and second time. I will also document if there is a significant delay in getting the med from pharmacy.

I want anyone who wonders why it took so long for the patient to get relief to be able to look at my charting and say, "Well, the doc took an hour (and two pages) to call back, and pharmacy took another hour and fifteen minutes (and a follow-up phone call) to send the med." Then I'm off the hook for the med not being given in a timely fashion, and I'm actually showing that I did keep after people until my patient got what she needed.

In addition to covering my anatomy, this kind of charting can be of use in demonstrating docs that have a habit of responding slowly or problems with specific meds or pharmacists.