Documentation of times

[hlnorrn]

I am trying to find information on the documentation of times for when a patient is off the unit (ex. going to radiology). I document the time a patient leaves and then the time they return but others say that the nurse should not be responsible and that the ancillary department should do it. Does anyone have any information on this?

Thank You!

[YoutubeTheNP]

Well everywhere I worked as an RN, the nurses had to do hourly rounds on the floor. So I would advise you to document "patient away at exam" etc in your hourly rounding notes. Don't ever expect someone else to do it, especially when you're the licensed one.

[socoamaretto]

If you can, yes. It shows you are aware of where your pt is and whether they are off the floor or not. You are offering more comprehensive documentation it's easier if someone asked you a question about it and easier for someone else to know in case they glance at the chart.

[HeySis, BSN, RN]

Even if someone else was "responsible" for documenting off the unit times I would still do it myself. It's a CYB thing. If anything were to happen, I wold want the exact times I was not responsible for the patient in the chart.

[Meriwhen, ASN, BSN, MSN, RN]

We do q15min rounds in psych. Should the patient leave the floor, it's marked on the rounds sheet as patient being "off unit." I also chart the times off and on in the EMR under Interactive View.

I'll include the trip in my note and how they tolerated the procedure (and any results if they're back) but since the times are already on the rounds sheet and the EMR, I'll leave those out.

[hlnorrn]

Thanks everyone. It is my personal practice to document the time they leave, how they were transported and when they returned. I am looking for literature or best practice so that I can share it with those that don't document times.

[MunoRN, RN]

If the times the patient leaves and returns the unit are being documented elsewhere (this is usually done by the transporter or other ancillary staff), then I would discourage you from double-documenting those times. Most likely it won't be an issue, but the problem is if the times you documented and the times someone else documented differ then this can become a big problem in court.

[canoehead, BSN, RN]

OP, we could make a three page list of things that other people are responsible for, but nursing does it for them.

[HeySis, BSN, RN]

Thanks everyone. It is my personal practice to document the time they leave, how they were transported and when they returned. I am looking for literature or best practice so that I can share it with those that don't document times.

I'm not sure that you'll find best practice in literature that defines who completes the documentation of off unit times. Because that type of documentation does not require a license, it is normally a facility policy issue. Best practice may define the RN to monitor and makes sure it happens according to facility policy. Of course in this area it means doing it yourself is probably easier then monitoring and making sure someone else did it.

If you find something in the literature, I'd love to read it.