Documentation

Published

I could have sworn that I was told once not to include names of individuals when charting. ( i.e. a CNA charts that "so and so, RN" was notified of a vs that wasn't even critical. ) I thought it had something to do with legal issues and names don't necessarily have to be dropped. Does anyone have any info on this kind of thing? It has become somewhat of an issue where I work.

Up Vote Up Vote ×

Im not an official nurse yet or anything but in school we are "taught" to avoid the use of names........however, I have found nurses who do use names in order to cover their own buns. I think its smart.... but what do I know?...Im just a student. :D

Up Vote Up Vote ×
Specializes in ICU/Critical Care.

Yeah at my last job we weren't even allowed to chart "Paged Dr. So and So regarding "blank". No call back received"

Guess the docs didn't want to be held accountable for not answering their pages.

Up Vote Up Vote ×
Specializes in Community Health, Med-Surg, Home Health.
Yeah at my last job we weren't even allowed to chart "Paged Dr. So and So regarding "blank". No call back received"

Guess the docs didn't want to be held accountable for not answering their pages.

I was under the impression that we should be able to chart names when we document. How else can we prove that we attempted to contact or consult with someone? And what their response was?

Now, when I was in school, we were told that what we should do, is avoid 'negative charting', and a scenerio was discussed similar to what you just mentioned. Instead of documenting "Paged Dr. So and So regarding blank and no call back received", we would continue to document the time and what was done, such as:

1530 Paged Dr. Feelgood regarding blank.

1545 Paged Dr. Feelgood regarding blank.

1600 Paged Dr. Feelgood....

In other words, it is saying the same thing, but not saying...ya know (ridiculous, I know...), but, it doesn't sound accusary on paper.

I am an LPN, who is (allegedly) supposed to be licensed to care for stable patients with predictable outcomes (yeah, right!). If an unusual circumstance occurs, I am supposed to document my observations, who I spoke to (meaning the doctor or RN) and then document what was done after that. I am not supposed to act independently in a crisis, therefore, I can't see why I'm not supposed to. I am sure most RNs would document if they contacted the nursing supervisor, nursing administrator, physician, social worker, or whomever...maybe I am naive, but, shouldn't it show somewhere how the nurse intervened?

Up Vote Up Vote ×
Specializes in Community Health, Med-Surg, Home Health.

Oh, and I do agree with you that the doctors don't want it documented how they ignored our pages, for sure...

Up Vote Up Vote ×
Specializes in ICU/Critical Care.

We could chart "dr. so and so paged in regards to whatever. Order received for whatever". Yep no negative charting allowed.

Up Vote Up Vote ×
Specializes in Community Health, Med-Surg, Home Health.
We could chart "dr. so and so paged in regards to whatever. Order received for whatever". Yep no negative charting allowed.

I would love, sometimes, to chart the truth; "Paged Dr. Idiot, he is too lazy to respond, I am ****** off, and am sending an execution crew, NOW".

Up Vote Up Vote ×
Specializes in ICU/Critical Care.
I would love, sometimes, to chart the truth; "Paged Dr. Idiot, he is too lazy to respond, I am ****** off, and am sending an execution crew, NOW".

:roll

Up Vote Up Vote ×
Specializes in Emergency.

I chart "Verbal report recieved from Sara Smith RN; patient resting, c/o pain 0/10, awaiting lab results; will continue to monitor", or "Insulin pump settings verified by second RN (Sara Smith)". I will continue to chart "MD notified, no orders received". I always chart that I notify an MD about something - its our job to monitor the patient and their response to treatment, and if its the treatment isn't working I'm darn well going to document it as such, along with the fact that I discussed the situation with the doc.

In response to your question "a CNA charts that 'so and so, RN' was notified of a vs that wasn't even critical." : I would think that it would be ok for a CNA to chart "VS taken, patient resting comfortably, primary RN notified of current VS."

Up Vote Up Vote ×
Specializes in Home Health currently, med/surg prev.

I understand it as the posters above -names can be charted but keep it positive. That is easier said than done at times though.

Up Vote Up Vote ×
Specializes in ER/EHR Trainer.

Always chart the facts...Dr ...informed of current vitals and condition-no orders received. Ob resident Dr ....on site evaluating patient.

If a problem occurs it will not be my behind! We are encouraged to write every visit if we can....with names, of physicians that see our patients. If physicians are worried about litigation, they should respond promptly and give orders. I can guarentee, if the patient's condition changes and we don't notify them, they'd throw us under the bus in a second!

Maisy

Up Vote Up Vote ×

It's not so much the charting of notifying a specific doctor that I'm inquiring about, but more of a CNA.... she's in school for the moment, but on a consistent basis practices OUTSIDE of her scope of practice. I've brought it to the management's attention, but nothing has been done about it. This was the scenerio....a baby ( I'm a pediatric nurse on a med-surg floor) was very agitated and upset when the vitals were taken. The HR was 149 for a 2 yr old, which is not detrimental, considering the circumstances under which the vitals were taken. She charted the HR and then annotated that "So and So, RN, was notified". I totally understand the importance of charting and charting correctly, however, there is a fine line of "over doing it". What really peeves me, is when it's charted that I was notified and NOTHING was ever said to me, or better yet, I'm in a near crisis situation and they (the techs) find it necessary to tell me of something so silly when I'm in the big middle of something. If the patient has a known history of abnormal vitals, then that's their baseline. If they are fit to be tied and completely po'd and the vitals are higher, then that's to be expected. If they have had NORMAL VS up until that point, then by all means, tell me and right away. This "CNA" has been caught telling patients of their medications, their discharge instructions and the list goes on. I've tried to confront her in the most delicate way possible, but it seems to not be working. I even approached her about throwing out names in charting when it wasn't necessary. I guess she went to managemnt, because there was an email a day later about "charting with the names of you told". I guess it really chapped me that she did that, but even more so, because I think I'm right on this. I've tried to go online and find documentation DO's and DON'Ts but, I'm coming up empty handed. Guess I'm going to have to check out BAM or Barnes & Noble and read up on it. But at the same time....every facility has their "OWN" policies that they go by, regardless of what is common for nursing.......thanks for all the input, my wonderful colleagues!!! :)

Up Vote Up Vote ×
+ Join the Discussion