Documentation

kmoonshine, RN · Jul 19, 2008

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!!! :)

It's the RN's job to take the data and act accordingly. You've pointed out that it frustrates you when CNA's document that they told you about something when they actually didn't - and then you state you are frustrated that they tell you of something silly when you're tied up. It shouldn't be expected of them to make decisions based on the data - it should be expected that they report the data to you. So, would you rather have them tell you about something, or would you rather have them NOT tell you of something? If you delegate something to a tech, such as vitals, then you need to follow up on it to make sure it's done. A CNA charting that you were notified is a good thing, as it shows that there was follow-through and that you were supervising the CNA's work.

I personally think its fine for a CNA to chart the vitals and that the primary nurse was "aware". Notified makes it sound urgent, however, both "aware" and "notified" mean the same thing. What's not fine is for a CNA to chart that they notified someone when they actually didn't. When this happens, make a copy of the chart page and address it with management. Also address it with the CNA and let them know that it is illegal to chart falsely, and if they are going to chart that you are notified of something then they need to actually notify you. Also state that they can't chart something before they actually do it.

If this false documentation happens with abnormal vitals (ie CNA charts "RR=68, Sara Smith RN notified") and you arent notified but it is documented as such, write your own documentation saying something along the lines of:

"1934 (time): Writer approached by pt's mother who states 'my kid seems to be having trouble breathing'. Writer immediately at pt's bedside, etc...". Your documentation should reflect when you were alerted of a situation and should be objective.

It is never ok for a CNA to be discussing the patients medications or discharge instructions. If they are, then they are practicing nursing without a license. CNA's can reinforce some discharge instructions (such as using crutches) but the CNA shouldn't be the one discussing discharge planning - especially if the RN hasn't reviewed that info with the patient yet. If this is happening, it needs to be addressed by management before something bad happens.

Charting names is fine as long as it is accurate. I know that I've been upset when I saw a tech chart "kmoonshine RN notified". Just seeing my name in the chart upset me. But I got over it, because I was the nurse and I was notified. Aim your focus on charting that is OBJECTIVE and ACCURATE, and address anything that falls outside this with management.

Ima Nurse · Jul 19, 2008

Is it common for CNA's to chart in the nursing notes? I've only worked in one hospital, but none of the CNA's in any dept ever documented anything in the nursing notes. They would record vitals on the vitals flow sheet but that was it. Also, that's how it was at the various other hospitals that I did clinicals at in school.

Just wondering if it is common or simply something that is done at the OP's facility.

pagandeva2000, LPN · Jul 20, 2008

Unfortunately, CNAs are not taught to assess, so, they really don't know what information is silly, versus what is not...but I do know that sometimes, some CNAs try to grate your nerves on purpose. Bottom line, again, is that they are supposed to report and if we start telling them "Only come to me when such and such...", that draws the fine line between reporting and asking them to assess, which is not their function.

I also agree that they should not document that a nurse was notified when they were not, because that is not fair to us. You cannot intervene on something you are not aware of. I have had RNs document that they gave me report and they have not. That leaves me out there, and I hate that. I am an LPN, and I make sure that I inform the RN exactly what is going on and why I am reporting it to them. Also, when I chart that fact that I reported to any medical person, I try to use 'gentler' words, such as 'consulted, informed, collaborated', so that it does not look like an accusation.

Of course, no CNA should be part of discharge planning, teaching about medications, or any nursing functions, because it misinforms the patients and that is not safe.