Cya basics

I've been an LPN in LTC a year. And I can tell you it is complaint city. Best way to CYA is knowing your problem, knowing the most prudent nursing intervention for that problem and documenting that you done that accordingly. For ex. Take ms jones, the resident who complains about the milk being spoiled, the meds making her stomach hurt, the CNAs not caring for her. The Nurses don't come see about her etc etc. Her family member is always in the DONs office threats to sue the facility. This would CYA.

1100: Alert and Oriented. C/O cough and congestion. Breath Sounds clear. Denies SOB. O2 Sat 98 percent. V/S WNL. Resident denies the cough and congestion is emergent and aggressively denies the need for ER transport. Notified MD Charlie Brown. Receiver order for Robitussim 15cc q4hr. Notified R/P Lucy Ricardo. Voiced understanding and appreciated call. Elevated HOB. Encouraging fluids. Ensured call bell was c in reach. Continued to monitor. B. Boop, RN/LPN. "

You see you took the appropriate nursing action r/t the problem so you CYA. Knowing which residents have Batcrap crazy families will help too and you'll learn.

This is a good topic! Ummmm...

1. Always chart on change in conditions, incidents, anything you think should be mentioned... Going back and doing a late entry isn't the same.

2. Don't leave pills in the med cart unattended (you'd be surprised at how many do this.)

3. You know those huge processes? Admissions, sending a patient out..? Make a checklist of all the things you need to do. (In accordance with the facility policy.) for instance... A change in condition. Checklist would include calling family/RP, calling MD, filling out SBAR, etc... Forgetting a key step is a common way to get written up.

4. If medications are refused don't forget to document (circle on MAR and fill out the back side.)

I'll come back if I think of more.

1. Don't just document in the chart. Call people and notify them of the condition or put it in the doctors book. Call your DON and docs on call and document in your charting that you called them. Being a newer nurse my first skin assessment I did and charted it, but I didn't put it in the doctor's book because I thought someone was looking at them. Now I put everything in the doctors book that is concerning at all AND document in the chart that I did. I also call my DON any time there is a major issue. I know which things can wait until morning, but I still call and leave a message at least.

2. I initial everything I do. When I take new orders I chart it and include in my charting that new orders were received, that they were noted in the MAR (or TAR), AND that they were faxed to pharmacy. I just started doing that recently as a CYA.

3. Oh, IV bags I've started labeling them with the date and time they were hung and my initials. I know I was taught that in school, but most NH nurses don't seem to do that and I didn't initially, but I do now. It's another CYA.

4. Date and initial all your dsg changes. I am amazed that there are people that don't do that.

5. This one's silly, but I do it all the time. I write on my med cups write before I pull them the resident's name & room number. This way if someone distracts me as I'm walking down the hall I don't forget where I was going or who I was supposed to be going too. Especially during heavy med passes because I find that people interrupt me and then I sometimes have to think about what I was doing. I also write on my med cups things like check O2 or check LS or whatever so I don't forget to do it.

6. Check, check, and check again your meds. Pay close attention to number of pills sometimes it will say more than 1. Also pay attention to things like IR and ER. I've had people on the same drug, same dose, and one IR and one ER. Very confusing so take your time on that one.

That's all I got for now. If I think of anything else I'll add it.

Any time a patient acts annoyed, rude, hostile, or unhappy in any way (or family, for that matter), let your charge nurse know how the patient is acting and chart on how you responded. For example: "Patient refuses to wear BiPAP mask, states 'I don't want to wear that ****ing mask.'; Pt informed of indication for BiPAP mask and implications of not participating in this care process. Will continue to educate."

Know how to handle "disruptive" prescribers and how to deal with hostile/disruptive workplace situations. Know your chain of command, aka: who and in what order you notify superiors if you are not getting what you need for a patient. That one is huge.

Easy answer...follow your P and P and professional standards. Remember....if it wasn't documented, it wasn't done.

One that was told to me from one of my instructors is to get someone between you and the problem whether it be a doctor or DON or Charge Nurse or whoever you can, i.e. "doctor blankity blank informed of condition" that kind of thing. And another one that was told to me was don't chart on a problem without charting a solution and what you did to solve that problem.

I've seen a couple of people say they will chart "will continue to.." and I have to say, this is a big no-no, and is the OPPOSITE of CYA. You can NEVER chart something that you will do in the future, only things you've ALREADY done. That's documentation 101.

I've seen a couple of people say they will chart "will continue to.." and I have to say, this is a big no-no, and is the OPPOSITE of CYA. You can NEVER chart something that you will do in the future, only things you've ALREADY done. That's documentation 101.

Like if you were documenting something occurring at the end of your shift and you said "will continue to monitor" Well, did you come back to work pro bono so you could continue to monitor'? Oh, and what's the appropriate time interval in which to come back to monitor?

That phrase is one of my pet peeves in documentation that make my teeth grind.

Thank you. I always found this entry silly to me.

Like if you were documenting something occurring at the end of your shift and you said "will continue to monitor" Well, did you come back to work pro bono so you could continue to monitor'? Oh, and what's the appropriate time interval in which to come back to monitor?

That phrase is one of my pet peeves in documentation that make my teeth grind.

Yes! I agree! But I have inexplicably found myself typing it!

I was taught to chart that while working as a psych nurse assistant, what would be a better ending to put? Vitals? Once I started to chart that by habit almost putting it in a residents chart that bad gone home, I agree that it can be a bad habit,