Recently a patient and family member questioned me what their physician was saying about the case, we reviewed the notes together with the permission of the patient.
Both the patient and the family member who intentionally stayed at the patient's side to act as an advocate denied that the physician had been in to the patient's room that day even though there was a complete head to toe assessment with problem list and plan.
The patient now stated that since I am aware that there is documentation that they say is fraudulent I am being held accountable by them to report the incident, which after confer with the house supervisor on a weekend I reported to the unit manager.
I have been questioned multiple times regarding this incident and the issue continues to be the discussion with the family not the fraudulent documentation of the MD. I feel like my job is in jeopardy now even after a conversation with my manager.
Will human resources or any other pathway be helpful in preserving my position. I will be completing my BSN in December and will have more flexibility after completion of my degree to change facilities.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
It's better that they never know about it?
No, it's better that the physician actually discusses it with them rather than just putting it in the note. It is not up to the nurse to discuss it with them. It not up to the nurse to review the doctor's note with the physician. If the patient or their decision maker needs to go over the actual doctor's note, they can do it in the manner mandated under the policy of that particular institution.
How did you get "never" out of the quote above? psu clearly states that s/he would refer this to the appropriate physician to discuss with the client, not that the client will "never know about it." Where are you getting the idea that the only two options for clients are a) being allowed to read their chart whenever they want to or b) living in ignorance?
If we're still discussing this in the context of the OP, then the example was mentioned in a prog note, which means they've already been to see the patient and didn't mention it. It's not all that unusual for a Physician to note a finding unrelated to their focus and never mention it which ideally they would take responsibility for making sure the patient is aware, but in the end it is the nurse's responsibility to ensure the patient is aware of all of this information. So if the nurse is always assuming a physician will do their job for them it's quite possible it frequently won't happen.
If we're still discussing this in the context of the OP, then the example was mentioned in a prog note, which means they've already been to see the patient and didn't mention it. It's not all that unusual for a Physician to note a finding unrelated to their focus and never mention it which ideally they would take responsibility for making sure the patient is aware, but in the end it is the nurse's responsibility to ensure the patient is aware of all of this information. So if the nurse is always assuming a physician will do their job for them it's quite possible it frequently won't happen.
No one here is talking about wanting or expecting a physician to "do their job for them." And every place I've ever worked, it would considered highly inappropriate (perhaps even a firing offense) for an RN to inform clients of their diagnoses and/or interpret lab or imaging results for them. Reinforce explanations/teaching that the physician has already provided, yes. Bug the physician to suck it up and have the difficult conversation with the client, absolutely. Be the first to break the news about a serious diagnosis, no. That is not the nurse's responsibility anywhere I've ever practiced, and I've never heard anyone suggest a scenario in which that could possibly be the nurse's responsibility.
Thank you for the replies to my situation. I have come to the conclusion that I will not be fired for this incident but it is likely that progressive discipline for other unrelated infractions will lead to my end of tenure at this facility.
I am very surprised about the distrust of patients in a hospital. The patient's goal is almost always to get better. It has been said here that raw information is not required for informed consent. What is needed then? If a doctor says suspicious of malignancy, it will worry a patient. Almost every patient in the hospital thinks they might be dying of cancer. All the notes and internal documents related to a patient's stay are discover-able.
I have read my policy regarding patient's ability to review chart after searching over thirty minutes to find it. The policy was very different than explained by a director. For all the people that are quoting your policy, have you actually found it to read? how long did it take to find? Was the policy you read the same as your supervisor or person who was responsible for orientation explained it was?
For those that have insinuated otherwise, I merely reported the patient/family complaint to my supervisor to investigate. It was my responsibility to report patient concerns regarding care to the appropriate person, that is my facility policy and my accountability.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
Thank you for the replies to my situation. I have come to the conclusion that I will not be fired for this incident but it is likely that progressive discipline for other unrelated infractions will lead to my end of tenure at this facility.
I am very surprised about the distrust of patients in a hospital. The patient's goal is almost always to get better. It has been said here that raw information is not required for informed consent. What is needed then? If a doctor says suspicious of malignancy, it will worry a patient. Almost every patient in the hospital thinks they might be dying of cancer. All the notes and internal documents related to a patient's stay are discover-able.
I have read my policy regarding patient's ability to review chart after searching over thirty minutes to find it. The policy was very different than explained by a director. For all the people that are quoting your policy, have you actually found it to read? how long did it take to find? Was the policy you read the same as your supervisor or person who was responsible for orientation explained it was?
For those that have insinuated otherwise, I merely reported the patient/family complaint to my supervisor to investigate. It was my responsibility to report patient concerns regarding care to the appropriate person, that is my facility policy and my accountability.
It took me about three minutes to find my facility's policy -- and most of that was waiting for the computer program to load. All of our policies are easily accessible online.
And by the way, the policy was almost exactly as I remembered it. And yes, it was pretty much the same as our nurse educator explained, updated for changes in technology.
No one here is talking about wanting or expecting a physician to "do their job for them." And every place I've ever worked, it would considered highly inappropriate (perhaps even a firing offense) for an RN to inform clients of their diagnoses and/or interpret lab or imaging results for them. Reinforce explanations/teaching that the physician has already provided, yes. Bug the physician to suck it up and have the difficult conversation with the client, absolutely. Be the first to break the news about a serious diagnosis, no. That is not the nurse's responsibility anywhere I've ever practiced, and I've never heard anyone suggest a scenario in which that could possibly be the nurse's responsibility.
If there are questions you can't answer, or you foresee questions you won't be able to answer, then absolutely, defer to the MD. But if the patient asks what their potassium level is, you wouldn't just ell them?
If there are questions you can't answer, or you foresee questions you won't be able to answer, then absolutely, defer to the MD. But if the patient asks what their potassium level is, you wouldn't just ell them?
And if it's very high or very low ? What kind of questions will that prompt and are you in a position to answer those? I understand what you're saying but I think you run the risk of getting into the same kind of situation that the OP did it may just take a little longer to get there.
And if it's very high or very low ? What kind of questions will that prompt and are you in a position to answer those? I understand what you're saying but I think you run the risk of getting into the same kind of situation that the OP did it may just take a little longer to get there.
Of course I'm in a position to explain their condition to them, I'm their nurse, how else would it work? Would you just not replace their low potassium level until after the Doc has rounded the next day so they can explain hypokalemia to them? Or would you just secretly give them potassium replacement so do don't have to answer their questions?
I work within the same health system that provides care to myself, wife and children. We are allowed to view our own medical records as well as those of children under a certain age. Whenever I have a clinic visit I will check my chart a few days later, just out of curiosity. I've noticed some false and inaccurate information but nothing I'd raise a fuss over. I had been in with influenze symptoms, a full assessment was documeted, it was also documented that I was strongly encouraged to quit smoking. Much of the assessment that was charted was not really completed (pedal pulses weren't checked, abdomen not palpated or auscultated, pupils, reflexs, etc. not assessed.) I also do not smoke and never have. I think much of the charting includes smart text which the MD/NNP/PA has to go through to delete what doesn't apply, sometimes they miss a couple of lines. I wouldn't say that my provider gave false documentation, just made made an error omission or mistaken entry. Some providers cut and paste parts of their documentation, file it, then return later (sometimes much later) to make corrections or updates. If you see the documentation before they do this, yes it can look like false documentation but it's really just incomplete. I think that makes sense. I would only consider reporting false documentation if it resulted in harm to the patient or violated legal and ethical standads.
@shermrn Did you ask your provider to remove the statement that you were strongly encouraged to quit smoking? Having a false statement on your medical record can have repercussions on life insurance.
So I bring the WOW in. Pull up the doctor's note. It mentions the possibility of malignancy. The pt asks, "what type of malignancy is it? What is the treatment? What are my odds? Etc." I now have a panicked patient who has a ton of questions, and I have no answers. If they want to review a doctor's findings/notes, the doctor will be notified and they will go over it in the morning when the doctor come in.
YES, this. A possible/ actual malignancy, or other such critical data, is the sole responsibility of the PHYSICIAN to inform, and more importantly, EXPLAIN what it means, possible treatment, morbidity, etc etc
just because a RN might know every single thing written-- it's not our scope to do this...
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
YES, this. A possible/ actual malignancy, or other such critical data, is the sole responsibility of the PHYSICIAN to inform, and more importantly, EXPLAIN what it means, possible treatment, morbidity, etc etc
just because a RN might know every single thing written-- it's not our scope to do this...
And I don't get paid enough to deliver news like this.
Ruby Vee, BSN
17 Articles; 14,051 Posts
No, it's better that the physician actually discusses it with them rather than just putting it in the note. It is not up to the nurse to discuss it with them. It not up to the nurse to review the doctor's note with the physician. If the patient or their decision maker needs to go over the actual doctor's note, they can do it in the manner mandated under the policy of that particular institution.