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Discussion

Documentation Requirements

We are a small, rural hospital and have a department called "Outpatient Medicine" where we do a broad range of therapies, one of which is to attend radiology procedures.

We put PICCs in with US, attend medication stress tests to monitor the patient, assist with breast biopsies under US, assist with stereotactic biopsies, assist with thoracentesis under US, catheterize for VCUG...no interventional radiology and seldom administer any medications.

What type of documentation would you think would be required of an RN performing these duties?

Is a care plan/care path required?

Would anyone mind sharing their documentation records with me if you have one?

Do these procedures require an RN in attendance at your hospital?

Thanks,

Kathy

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    As a nurse who started off in a one nurse radiology department, this sounds very familiar. What I suggest is to go to your nursing admin folks who have a standard of practice for other areas of the hospital such as ER/SDS or GI and find out what kind of documentation they are using.

    If you are monitoring patients for procedures, then for the patients sake as well as your own you must at the very least have some kind of narative notes that document what you are doing, otherwise what would be the point. Go to the website of JCAHO and do some research on documentation for nursing staff there as well. If you hospital has electronic documentation, then contact the staff for that program and see if they can help to build or customize a documentation tool for your use.

    As for a carepath that would also be I think under the practice standards for your individual institution.

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