Documentation question, need opinions on this one

orthonurse55 · Jul 2, 2012

As a nurse that has been a patient, I can only say that we have to learn to change our roles when it happens. No, I don't feel a nurse as a patient has any right to interfere with the chart, aside from reading it if they wish to. Geez....micromanage?

Double-Helix, BSN, RN · Jul 2, 2012

When can a nurse write orders, period?

According to my hospital policy, patients cannot look at their chart without a hospital representative present. Nor can they EVER make any alterations to the chart. They are not medical staff- they are the patient- and have no right to make notations in their chart. If the patient wishes to see their chart, they need to make a formal request through the medical records department and a member of the department will sit with them while they review the chart to make sure nothing is changed/removed.

Absolutely, not at all appropriate. Review your hospital policy regarding this and escalate it to your supervisor. The hospital is legally responsible for the accuracy of the information in the chart. I'm sure that your medical records department would be furious to find out this was taking place.

klone, MSN, RN · Jul 2, 2012

The most I've ever done as a patient is dumped the urine out of the hat that was in the toilet and wrote down the amount on a piece of paper.

nf nurse · Jul 2, 2012

I should have said wrote her own verbal orders from the doc. I agree, when I was a patient I acted as a patient not my own nurse. I think that she thinks since she works on this unit then she can do this when she is a patient also. I appreciate all the input so far.

amoLucia · Jul 2, 2012

I think there's a legal/illegal issue with conflict of interest here. I don't think any nurse there should be following any orders she wrote and I would also question the MD if he was aware of the situation.

Another thing that concerns me...as her co-worker, I would feel very uncomfortable with her 'checking' out my documentation as if I were being tested or graded. LIke what if she disagreed with something I wrote? And there's a trust issue there too. I don't know if I'd be comfortable working with her again.

That is NOT a good situation. All the other posters were right-on but I would absolutely take it to the highest level possible, including Risk Management. You all may be violation of an existing policy already if your admin gets really snitty about it , as if "what were you thinking, didn't you realize.......?"

KelRN215, BSN, RN · Jul 3, 2012

I've been a long-time patient longer than I've been a nurse and it would never occur to me to do something like that. The last time I was in the hospital was about 2 years ago... I was being worked up for a number of things and having frequent lab draws. One large hospital system in Boston has an online patient website where you can do things like: verify appointments, request prescription refills, read radiology reports, communicate with MDs, check lab values, etc. Did I check this site and see my lab values before some of the providers? Yes, but I had access to this information through my own personal computer... it's not my fault I was paying closer attention than the MDs.

I would never write something in my own chart and I would NOT seek medical care at my own place of employment. Fortunately, I won't ever have to since I am exclusively a pediatric nurse and I'm too old to be a pediatric patient. :)

Altra, BSN, RN · Jul 4, 2012

You don't need opinions on this one. You need the immediate input of your management.

netglow, ASN, RN · Jul 4, 2012

Illegal in every way.

What if she told you she took a verbal order for narcs, for herself?

OnlybyHisgraceRN, ASN, RN · Jul 4, 2012

She is way out of line. Doctors cannot even write their own prescriptions.

The most I've ever done as a patient was label my urine, and d/c an IV on my arm.

xoemmylouox, ASN, RN · Jul 5, 2012

This is insane. There is no reason for anyone to document anything in the chart, let alone "verbal orders". She/He could punt anything in there and say it was a verbal order.

classicdame, MSN, EdD · Jul 5, 2012

I believe the risk manager needs to be notified.