Documentation by PCT's

[jennilynn]

Help me to settle a continuous question at work....

What would you consider crossing the line in PCT documentation?

Here's the situation.....the PCT's document in the same area of the chart (assessment & intervention) for patient care, ambulation, etc., as the nurses chart their assessments.

Some techs will free text in the additional data area "patient alert & oriented, resting comfortably" (even when the pt is AMS, dementia, or in obvious distress. So their documentation and the nurse's aren't copacetic)

Some say this is an assessment and the tech is crossing the line as to scope of practice. Some say this is a non issue.

What say you?

[CalicoKitty, BSN, MSN, RN]

I wish our automated blood pressure cuffs could 'determine' respirations. But, if they are documenting something that isn't true, then, it is false documentation. If it is an assessment, then it shouldn't be part of what they document.

[xoemmylouox, ASN, RN]

Well I think that if they are going to document it needs to be valid documentation. It shouldn't be the same script for every patient. If they can't handle that then shouldn't be charting.

[Nurse SMS, MSN, RN]

Sure sounds like an assessment to me. But don't they sign their documentation? If so, it can only harm the nurse if she fails to document her own activities.

Techs are not allowed to document at all other than vital signs where I work, and those only on noncritical floors.

[canesdukegirl, BSN, RN]

Hmmm..just the phrase "resting comfortably" sends up a red flag for me. It is objective data that requires assessment. If the pt actually stated, "I am resting comfortably", then it could be subjective data, requiring no assessment, just a written record of what the pt stated to be true.

I think it IS a big deal to have PCTs record objective data. In my state, it is out of the scope of practice for a PCT to make assessments.

It also alarms me that the charting that the PCT is writing and the nursing notes do not coincide. Think of what a field day a lawyer would have with that kind of discrepancy!

[sauconyrunner]

It seems like it would be inappropriate for a tech to document thing that are not the case, just as it would be for a Nurse or anyone to document something that is just not true.

Therein lies the problem, not that the PCT is charting something, but that they are not charting appropriately to the situation. I does seem that they really should be limited to placing in the chart, I and O, VS, and things like, "provided pt with blanket/juice/slippers/soap."

[Maremma]

Hmm we are having issues with this same thing in the nursing home I work in. Our aids have an area in their computer charting where they can choose a prewritten statement or they can open a tab and type in in their own words whatever is conerning them about a patient. "Problems" have arised due to this. Some aids have been putting things in their charting area that the nurse would need to repsond to but never notifying their nurse of the problem. The nurse has to specifically look in a separate area for anything put in by the aids and may not even know there is one until the end of the night when she is checking that the aids completed all their tasks in the computer. I am fortunate that my aids have never done this to me but I have heard other nurse's complain about it. They go to assess the patient when they see it but it could be several hours and the patient is either no longer displaying the reported "issue" or has declined rapidly. Granted the nurse could write the aid up for not directly informing them immediatley but the harm to the patient has already been done at that point or the nurse is now facing an ethical delima. It is required by the nurse to do a coresponding SBAR on the change in condition of the patient so when the nurse goes back to assess for herself and the patient is no longer displaying any of the reported behaviors or symptoms she either gets written up for not doing the corresponding SBAR or she has to lie to make it match what the aid reported hours before. In our facilty the nurse is held accountable for everything that happens or does not happen from the time their feet hit the floor until they clock out at the end of shift. They neglected to tell us when we began working there that one of the job requirements of the LPN was to also be a mind reader and psychically know what the aid is seeing hearing and putting in the computer the minute they do it! reporting that the aid did not inform the nurse at time of incident doesn't prevent the write up because you are still to blame for not controlling your aids and having them report directly to you the minute something comes up. If you have a spiteful aid you are in a world of hurt.