documentation & pain

[Sunrise2009]

I hope this doesn't sound confusing. So I'll try to explain. Myself and another staff went in so that

I could remove a drain from the patient's leg. I cut the suture that was attached to the drain. The

other staff wasn't sure if the suture was cut, so she took the suture remover from me and continued

to inspect the drain & suture. Then she removed the drain. The patient screamed in pain like I have

never heard before. Then after the the area was cleansed and DSD applied, I was told to do the

charting. How should this have been documented? I did document that I had cut the suture and that

the other staff had removed the drain, and that the patient found this to be painful. The other staff

explained that the patient had been given analgesic before the procedure.

[Cosper123]

Was there a way to validate that the pain medication was given? Who ultimately was responsible for this patient?

I'd chart it as you did with just sticking to the facts and not adding anything additional to the info. For example I wouldn't put "screamed in pain like I've never heard before." I'd put it as "patient expressed pain" and then put anything they may have said verbally if it is pertinent. I'd have asked the patient to rate the pain and inquire if there was pain AFTER that needed to be addressed still.

But yeah basically how it happened short and sweet. Name the nurse that removed it since it wasn't you like such - I cut suture. Janice RN removed drain.

The only hangup I really see is that the other staff verbalized that pain medication was given. I wouldn't put that they merely stated it, I would make sure it was actually done before charting as such.

But I'm new, and look forward to the input of those more experienced.

[tewdles, RN]

Your obligation is to chart the facts of what happened as factually as possible. Remember that the documentation is simply a record (legal) of what was done to and for a patient. It is the best protection you will have if you are ever deposed in a legal matter regarding a patient you cared for. You may certainly chart that another nurse reported something to you being careful not to play "he said/she said games". You charting should reflect how the patient was doing after the procedure and the pain.

Unfortunately, drains are painful oft times when they are removed. Hence the premedication. Unfortunately, whatever was ordered was obviously not adequate. Sounds like you are perhaps a newer nurse and this was why another nurse assisted you? Good luck!