documentation

[nurse-rhe]

hello.

i'm a brand new member here and what a great site this is! very diverse and so much informative feedbacks!

i work at a big outpatient clinic, in internal medicine dept. i have a question regarding documentations, and i would appreciate any thoughts on this. this is pretty lengthy so pls bear w/ me. :imbar

we frequently receive faxes from snf and assisted living facilites daily re: many things, ie: medication problems, fall incidence, skin breakdown, bp/blood sugar issues, etc.... the nurses from these facilities prefer to fax their reports to our docs and they like the orders/comments from our docs, fax back to them w/ signature. we, nurses receive these faxes daily and once we get them, we put it straight in our respective mds inbox for review.

occasionally, we get calls from these nurses and get a verbal report from them, w/c we then document in the patients chart via electronic medical record (emr). after we place the documentation in emr, we send this to the appropriate primary care md and he/she responds to us.. and let us know what they want us to do. they will either ask us to call the nurse back and give a verbal order/instruction or they will write their orders on a piece of paper w/ signature and then we the nurses fax it back to the facility.

our docs like to have everything in our emr, especially when they have to cover for the each other on weekends. just a few days ago they sent an email to the nurses.... they had asked us nurses to transcribe all the faxes that we get (from assisted living and snf) to emr. then send that message to them, they will reply w/ orders/instructions... w/c we the nurses will have to write down on our order form and stamp the mds signature and fax back to the facility.

i was very shocked and annoyed after i read this email from the head md of our dept. it was never discussed w/us nurses.

i am not comfortable transcribing and transferring another nurse's report in our emr. i don't know what.... but i know there is something wrong w/this picture or am i being over reacting! is the fax report any different from the verbal telephone report we receive from the facility nurses? i figured, the fax report is a written legal documentation that was done by somebody else, and transcribing a written report to our emr is a medical error waiting to happen.

all nurses were very upset about this, not only it's very time consuming to be transcribing these faxed reports but everyone agreed that there is something wrong w/s this and no one wants to risk their license! no one has done any transcribing yet... we want to bring this up on our staff meeting. our rn supervisor is on vacation and i don't think she knew about this because she has never said a word to us before she left.

but for the meantime, i thought i will do some research and get as much feedback as i can before our staff meeting. please advise!

nurse-rhe:redbeathe

[gonzo1, ASN, RN]

I understand your hesitation in doing this. I think that risk management needs to check first and see if this is a proper use of the patients chart. I would wait for clarification from your manager and see if risk management can put some light on the problem.

[Straydandelion]

I am unclear why the docs want nurses to work in a medical transcription/Unit secretary category?

[mpccrn, BSN, RN]

i can see why the docs want faxes to be included in the EMR. i can see your concern in transcribing them. Seems the answer is an easy one that will please all parties. Have the department get a scanner. Scan the faxes into the medical record as the docs request and it leaves you personally out of the picture. yes, it's another 'job' for you to do but i think its a better situation than transcribing the faxes yourself. the lesser of all the evils. just a thought..........

[pielęgniarka, RN]

Yep this is what our facility does-- scans the faxes from outside the facility to upload internally to the med. records. We leave a progress note: "refer to uploaded documents re:___________". I would also not like transcribing another nurse's note. If I had to I would make a generalized script and keep it brief. "Fax received from _______. Nurse (name here) reports ________ and would like follow up orders from PCP." Or whatever.

i can see why the docs want faxes to be included in the EMR. i can see your concern in transcribing them. Seems the answer is an easy one that will please all parties. Have the department get a scanner. Scan the faxes into the medical record as the docs request and it leaves you personally out of the picture. yes, it's another 'job' for you to do but i think its a better situation than transcribing the faxes yourself. the lesser of all the evils. just a thought..........

[nurse-rhe]

Yup, I thought about the scanner too. I will definitely bring that up. I think that what irritated me the most was the fact that the docs implemented it w/o even speaking to us first, like we don't have a say on anything?

[LegallyBlondeEck]

As technology in health care moves forward, we're going to have similar issues arise but especially in how we address the EMR. I have worked on both sides of this 'faxing' scenario and there are a couple of things to consider. First, hopefully they will wait until the Nurse Supervisor returns from vacation before implementing such a big change. He/she may have some prior experience or important feedback to take into consideration before making any changes. The RN supervisor may even want to hold an in-service and cover how this new policy will go into effect and mechanisms for feedback for any issues that arise once you've begun. Finally, it's very difficult to put our signature to something that we didn't author. Especially in the litigious society that all nurses are taught to be aware of from our first day of nursing school. If I am going to type or write someone else's words into a medical record; I am sure to inlcude quotation marks around the "entire quote" and include the date and time the fax was received and who signed it. There are two disadvantages of 'faxing' doctor notifications from ALF/LTC or anywhere else. When a nurse calls you with the COC (change of condition) whether it's a fall, injury, skin tear, med error, abnormal lab etc; you've got the opportunity to ask for additional information that you feel (or know) the doctor would want clarified. You don't have that same advantage with a 'fax.' Secondly, you could, potentially, at the time you've got the ALF/LTC on the phone be typing in to the EMR as the call comes in and thus preventing having to type these 'faxes' in as they accumulate as well as delays in getting the information inputted while it sits at the fax machine, waits in a box, waits in a stack, etc. Change isn't easy, make sure you have a go-to person that can address your concerns as they arise if you are directed to input these faxes in to the EMR. Also consider giving your ALF/LTC a written guideline to follow when faxing important COC/medical information to reduce the number of clarification calls. One thing that I'm not sure of is if the doctor's are looking to pull this information off of the EMR directly instead of reading the faxes or if they're writing orders off of the fax but want the information put in the EMR in addition to the hard copy in the file. This would = double charting. In this event, maybe a smaller entry in the EMR would suffice noting you are now summarizing someone else's report, the hard copy's in the paper file and summarizing someone else's report is a sticky subject, too. Good luck!

[nurse-rhe]

thanks for the feedback. We the nurses discussed this a few days ago, since the nurses were not sure on how to approach the situation, no one has really made an attempt to transcribe anything. We all insist to our supervisor to show us our facility written policy about this issue, and I wasn't surprised that we don't have one because this topic has never really come up before, atleast w/ the other departments. I'm really adamant about doing any transcribing, it just doesn't feel safe to me. Thank you so much for your reply.