documentation and getting MD orders

Nurses General Nursing

Published

  • by rnto?
    Specializes in Med-Surg, LTC.

I am a weekend charge RN in a sub acute facility. It is my job to get report from the nurses on the floor, determine what to do/if I need to call the doc, and then recieve and write orders. This AM I was told by the night turn nurses that three patients were severely agitated/awake all night, one was striking out at staff, etc. I totally believe this. Before they left I said, make sure you have documented these behaviors. They said they had. THe night turn supervisor, (whom I've previously had run-ins with) pretty much ordered me to get something ordered (meaning psych meds). That aside, I go to check the charts to see what happened, to have some tangible evidence to go on when I call the doctors, and on every patient they stated was agitated, the note reads like an uneventful night, with an assessment at 10pm that the patient is either sleeping/easily arousable or alert with confusion, and that's it regarding psychiatric status. I do not feel comfortable getting orders for psychiatric medications (chemical restraints, anyone?) with NO documentation about the behaviors, why they are needed, etc. I have a call out to the ADON, but what do you guys think?

roser13, ASN, RN

6,504 Posts

Specializes in Med/Surg, Ortho, ASC.

I don't see how you could possibly take action on the verbal report when documentation is not present. Don't forget the old standard...."if it wasn't documented, it didn't happen."

I'll be curious to see how your ADON handles the situation.

rnto?

122 Posts

Specializes in Med-Surg, LTC.

thank you so much. The night turn supervisor acted like I was the one in the wrong. I'm anxious to hear what my ADON says, too. More than likely she'll blow it off, and act like it's nothing, although I deal with this every weekend. Part of the reason I'm looking for a new job!

talaxandra

3,037 Posts

Specializes in Medical.

I'm with roser13 - it'd be really hard to support your asking for meds when the nursing documentation not only doesn't mention any agitation but actually says the patients were settled. I fanything happened - a reaction, a family member being unhappy - you'd be alone out on a limb.

sweet sunshine

64 Posts

Why can't the night shift call the md themselves?

Whispera, MSN, RN

3,458 Posts

Specializes in psych, addictions, hospice, education.

I'm with sweet sunshine...if a patient is awake and agitated, he or she is in extreme mental distress and needs help. To wait for morning to get an order for a med is surely not being a patient advocate. I feel very sad and angry for the patients.

The nurses who verbally report agitation and don't chart it are not doing their job appropriately. They need to be talked-to.

pennyaline

348 Posts

Night shift staff is perfectly capable of taking the responsibility for what it does. THEY can call the docs, THEY can get their own orders, and THEY can accurately chart the behaviors.

Getting calls in the middle of the night is routine for doctors on call. Making calls in the middle of the night to doctors on call is routine for nurses who work nights. There is no reason for you to make calls and get med orders for something that happened on the night shift.

CathyLew

463 Posts

Specializes in MSP, Informatics.

I would wait till either you had the documentation...or you saw the behavior yourself. and why didn't the night supervisor call the MD? I do understand that sometimes lists of things to ask the MD for are left for the day crew, but a behavioral issue that is happening on nights should be handled by nights.

rnto?

122 Posts

Specializes in Med-Surg, LTC.

update: DON told me to get orders for the benefit of the patients. One of the doctors was asking specs about the behavior, I had to apologize and expain that I had no idea, etc. I talked to night turn girls when they came in - told them I wasn't leaving until things were documented, was very professional about it, positive reinforcement/constructive criticism etc. It ended with the night turn supervisor telling me she's been a nurse much longer than me, is the only one that gets things done on night turn, and doesn't call doctors on the weekend at night unless someone is dying because they don't know what they are doing when they are on call and they get mad if you wake them up. She pointed to one of the patients and said, "Is daylight documenting about that?" meaning the patient's yelling/singing at the top of her lungs (which she apparently was doing all night and keeping other patients up). I did my best to redirect and keep it about the issue at hand, not 'I'm a better nurse than you are" type of banter.

I am speaking with the DON tomorrow, about this type of thing and other issues. I'm very frustrated with my job!

Thanks for all the input, I love allnurses.com!

+ Add a Comment

By using the site, you agree with our Policies. X