not documented, not done. what does this mean?

[kmahoneyrn]

i am looking for a respnce to the statment 'Not documented, not done." Was this taught to you in nuring school, in clinical practice or it is a part of your policy manual, or all three?

[Sleepyeyes]

Originally posted by Tiiki

I had on MD actually correct my charting. It was a horrendous day, and I charted on one pt the following.."pt in pain, breakthru given." I figured since there was only one narcotic break thru PRN med I was clear. NOPE! The MD wrote in RED!!! "WHAT MED? WHAT DOSE?" That taught me to be very specific about everything, from am to hs care. I have found it also covers your ass if a family member or patient for that matter starts complaining of the quality of care given.

Cheers!

Jo-Anne :)

At our facility that would be considered redundant because the med dose, signature, time, assessment and re-assessment are checkboxes on the MAR. But I still may write a little blurb like you describe to give the doc a head's up about the pain med's effectiveness. :)

[KaraLea, LVN]

Sleepyeyes, I love your signiture line...I live in the Texas Hill Country and our canyon just celebrated it's sesquicentennial this past weekend and we used that verse for our theme.

[Fgr8Out]

Charting what we as nurses do for our patients is critical. Thankfully, flowsheets, MARs and the like make much of it easy with just a simple initial. Charting specific conversations and observations in Progress Notes or Computer Charting is vital to... as many others here have stated: CYA.

HOWEVER,

Be careful HOW you choose your wording. We had a patient who experienced oversedation with a morphine PCA. The nurse attempted to awaken the patient before administering narcan. Her documentation of the event, however, did not read very well... "Patient appeared lethargic, unable to awaken. Pt shaken without response. Sternal rub, with little response. Slapped patient across the face to try and awaken without much effect...." SLAPPED PATIENT ACROSS THE FACE?!?!?!?!

Let's just say this nurse had a long, DETAILED discussion with our Supervisor, following this little piece of documentation. Believe me, she's much more careful with how she phrases her comments now.

[Aussienurse2]

In Australia the Govt subsidises health care. So we have to document EVERYTHING, from technical nursing procedures to daily activities like T.V., listened to music, attended concerts but especially encouragement to attened to themselves, like choosing what to wear, washing thier own hands and faces etc. Mobility, chair, w/frame, hoist or stand and pivot etc. If it's not done we loose money and nursing hours. LOL!! Even visitors how many and duration of visit!! Money is a big incentive to get the paperwork done!!:) Plus we have the added benifit that the residents family and doctor have to be a part of the group formulating the nursing care plan so no-one can say that they didn't know what was going on.