documentation opinion question

[RedSoxRN]

Hi all, just an opinion question, trying to keep it simple here....

When writing an admission note on a patient, is it acceptable to write specific things that were reported to you as it relates to admission reasons?

I had a patient who came in with fevers, respiratory distress, 4/4 positive blood cultures, and hypotension..... septicemia.

Is it wrong to write "Per report, positive blood cultures at (outside hospital)"? Sure, I didn't draw them myself and ensure proper technique, nor have I seen the micro report, and positive blood cultures aren't my problem in terms of scope of practice, but it was repeatedly discussed with the interdisciplinary team, and acknowledging that as part of the picture on admission shows focus for nursing priorities, correct? We're expected to write a general summary of admission reasons. Just looking for what you think.

[jmgrn65, RN]

IMO i would say chart it, just the way you did in your post, so at least there is documentation of what was said. If anything else it covers your but.

[Mags4711, RN]

I would ONLY chart it this way:

"per report from Stacey Nurse, RN from the SICU at University Hospital in anytown, the patient has positive blood cultures. Please see MD admission note for specific dates and organisms."

I rarely, if ever, chart something someone else reported or wrote. I can understand in this instance it is one of the reasons the person is being transferred to you, so I suppose you could document what you received in report.

I never write vent settings in my notes, nor results of labs, ekgs, CT's, nothing. I will write the date of the MD note or the date the study was done to refer a reader to the actual results. For vent settings, I state: "Please see RT flowsheet for complete ventilator settings, changes and ABG results."

Why, you may ask? Because if later on if the patient develops a pneumo (and someone sues), and the PEEP was 15, but I've charted 16 or 17, who is the court going to believe?

[RedSoxRN]

It can be so frustrating that we have such a limited scope of practice in some ways. We are expected to intervene on all sorts of advanced data, but when it comes down to it, we're not allowed to say what the data is indicative of. And the more frustrating aspect is the way the real world works... the true reality of RNs frequently guiding house officers/residents in their own care plan of the patient, because often the RN is more experienced!!