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Documentation and legal concerns

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by timpanzee timpanzee (New) New

I hope someone with legal experience can answer these questions. I went to a nursing law seminar and was told (I beleive) that if you report an incident to someone (DON, administrator) that you should document who, what, when, etc in the patient's chart. My administrator does not believe that this is true. I had an incident which required an incident report, and I wrote that he was notified. MD or family wasnt needed to be called. Anyway, big debate on this issue. Can anyone advise me on when to and not to document who was reported incidents to.

Second, I was told at work today that LPN was giving CNA's OTC meds to help them stay awake. I say this is dispensing without license, but again my administrator states this is just like anyone giving anyone tylenol, etc. Also, he doesn't feel that LPN put facility in jeopardy. I disagree. He states that only Rx's given to other person would be legal problem. Please advise, and if anyone can refer me to good documentation websites I would greatly appreciate it.

Lorie P.

Specializes in Med/Surge, Private Duty Peds.

2 very helpful books are; The Nurse's Legal Handbook

and Chart Smart,The A-Z Guide for Better Documentation.

I use thses 2 books and have been very pleased with them.

Hope this helps!

See what state and federal law says about who is allowed to dispense meds.

Also, the LPN was asking the aides to work outside of their job description and delegating improperly. She had better hope you don't report her to the Board.

When you report to the DON or Sup or Administrator, chart to whom and when and what you reported. I've had other staff tell me that I am to never put their names in the chart. I do it anyway, so I will always know to whom I reported, should the matter ever come up later. I don't like my name in the charts either but understand if an aide or someone says they told me this or that.

Again, you might want to see what your state law or federal law says about these things.

2 very helpful books are; The Nurse's Legal Handbook

and Chart Smart,The A-Z Guide for Better Documentation.

I use thses 2 books and have been very pleased with them.

Hope this helps!

Thanks, I just ordered both books. I will let you know if they helped.

I was told this.....a long time ago....

#1 you never reference a incident report in a chart.

However.....when something goes down you take out a piece of paper and date it put a patient sticker on it and write all the things you wish you could right in the chart. i.e. page MD because his baby decelling (I am an OB nurse) MD says..."I am at my kids soccer game I will be there in an hour." in the chart you would write that MD states he will be here in an hour....

another example....I had turned off the pit on a patient who was having lates....MD comes onto unit reviews strip and restarts the pit herself....then tells me in the hall that she has an 0600 case and this patient HAS to be delivered by then....and not to turn the pit off again (which of course I did)

Basically if this ever comes to court in like 4-5 years #1 you won't remember all the details......and #2 If you can honestly say that you wrote all the details down at the time of the incident it is much more likely that you will be believed....

I keep them in my folder at home with all my CEUs and stuff....I always write down who I talked to, what their response was...chain of command ect....

Story...nurse had an issue....reported it to charge nurse...charge nurse states tells RN she reported it to house supervisor (RN thinks she has done her job and followed chain of command)RN also makes an incident report....things get bad....charge nurse now states that she was never notified of this...house supervisor says the same....incident report that was done on the hospital computer software by RN now does not exist.

NEVER underestimate the imporance of protecting yourself....never think that the people you work with won't sell you out in a second to save themselves.....never think that a hospital will protect and support you.....

I am not trying to be pesimestic and negative....but there are more politics in nursing than I had ever imagined when I became a nurse...

traumaRUs, MSN, APRN, CNS

Specializes in Nephrology, Cardiology, ER, ICU. Has 27 years experience.

Personally, I write who I notify of what...I never note that an incident report was made but if I do notify an MD, you'd better be sure I'm documenting it. And...if nurses tell me something, they document they told me.

I was told this.....a long time ago....

#1 you never reference a incident report in a chart.

However.....when something goes down you take out a piece of paper and date it put a patient sticker on it and write all the things you wish you could right in the chart. i.e. page MD because his baby decelling (I am an OB nurse) MD says..."I am at my kids soccer game I will be there in an hour." in the chart you would write that MD states he will be here in an hour....

another example....I had turned off the pit on a patient who was having lates....MD comes onto unit reviews strip and restarts the pit herself....then tells me in the hall that she has an 0600 case and this patient HAS to be delivered by then....and not to turn the pit off again (which of course I did)

Basically if this ever comes to court in like 4-5 years #1 you won't remember all the details......and #2 If you can honestly say that you wrote all the details down at the time of the incident it is much more likely that you will be believed....

I keep them in my folder at home with all my CEUs and stuff....I always write down who I talked to, what their response was...chain of command ect....

Story...nurse had an issue....reported it to charge nurse...charge nurse states tells RN she reported it to house supervisor (RN thinks she has done her job and followed chain of command)RN also makes an incident report....things get bad....charge nurse now states that she was never notified of this...house supervisor says the same....incident report that was done on the hospital computer software by RN now does not exist.

NEVER underestimate the imporance of protecting yourself....never think that the people you work with won't sell you out in a second to save themselves.....never think that a hospital will protect and support you.....

I am not trying to be pesimestic and negative....but there are more politics in nursing than I had ever imagined when I became a nurse...

What ever you write concerning a patient incident, also make a copy for yourself. Also, I would make a copy of my nurses notes, include any notes from other departments (ie Respiratory therapy) that were related to the incident, because they will disappear from the chart.

I have always noted in my nurses notes WHO I REPORTED THINGS TO!! Along with date and time. These very people will deny to your face that you informed them of anything. If these individuals are not happy that their names appear in your charting, so be it. It is their problem, not yours. Your problem is to CYA!!.

I have gone so far to also make copies of the incident reports that I hand in. I would also call the Risk Managment Department the next week, and make sure that the indident report made it down to their department. You would be surprised how many nurse managers don't turn in the incident reports made by the staff, especially if it relects badly on them for poor staffing, working conditions, etc.

Lindarn, RN, BSN, CCRN

Spokane, Washington

Anybody have anything to say about my second concern. LPN giving out OTC caffeine meds to staff. What is the legality of nurse on duty giving over the counter meds to anyone? Are we, as nurses, or as civilians, allowed to give out OTC meds? Is there any liability to this?

I though I was told that nurses are not allowed to give anything out (personal or not) because that is considered dispensing meds without a license.

I would appreciate the legal aspect of this from someone who knows the law. Opinions also accepted. Thanks for all input.

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