Documentation

[NewNurse08022016]

Hello fellow nurses :) Good morning!

if you have read any of my other posts you will see that I am a brand new nurse. I have not yet had to contact a doctor or fill out an incident report. Does anyone have advice on what information I should ALWAYS have in front of me before calling the doctor? I know their vitals, MAR & chart.

Also what do I need to make sure I include in an incident report? I'm very detailed & often I get a little wordy. Are there ever times where we would send them out for x Ray even if they complain of no pain & have complete ROM?

Now that I am out in the "real world" I'm seeing how much I really never learned in school. It's very scary to be a new nurse. & I just want to make sure I'm doing the right thing.

[Ruby Vee, BSN]

From your post, it appears as though you are working in LTC. My background has been ICU for the past 35 years, and while I can tell you exactly what to have in front of you when you call a physician for an ICU patient, I'm only guessing at what you'd need to call a doctor for a LTC patient. The people you work with will have the best answers.

In general, it is good to have the chart in front of you. Vital signs, I & O, current medications, most recent labs, current complaint, signs and symptoms will all be important, but focused toward the reason you are calling. If, for example, I'm calling about copious rectal bleeding, knowing the latest hemoglobin or hematocrit might be important but the magnesium level last month might not be. However if I'm calling about muscle cramps, it might be important. If I think the patient is in CHF, what do her lungs sound like, her ankles look like and what's her I & O? In this case, a spot of blood on the toilet paper from a known hemorrhoid is extraneous information.

As far as incidents -- brevity is important. You want to describe the incident clearly and succinctly and use facts only. "The patient slipped on a wet floor and fell, striking left elbow and the left temporal region," not "The lazy housekeeper left a puddle of water on the floor rather than interrupt her break to mop it up and the CNA just let the patient walk down the hall anyway, so of course she fell." You also want to be clear . . . WHO fell. How did they fall, were they injured and if so where, and what is the result of that injury? Any changes in vital signs? Bleeding? Obvious injuries? And never, ever refer to your incident report in your documentation.