Documenting Every Time 911 is NOT called

[SilverBells, BSN]

So, I am not sure who is familiar with how electronic documentation works in SNF settings.  However, as a brief explanation, in our facility, nurses mainly have two sets of "charting" that they are documenting on: the MAR (medication administration record) and the TAR (treatment administration record). 

 MAR documentation is pretty straight forward as you are just charting on medications you have administered.  You basically state yes that you gave them or no, such as patient refused, vital signs were outside of parameters, or patient was unavailable.  

However, the correct way of documenting on the TAR seems to be more open to interpretation.  

For example, many of our patients will have orders such as "Call 911 if resident is having chest pain, shortness of breath, increased weakness or any other concerns."  There are two options: you can chart 'yes' or 'no.'   For most nurses, they will chart "yes" to such orders even if they didn't call 911 with the explanation: "We are just acknowledging that should the patient have had these symptoms we would have called 911."  HOWEVER, we have a nurse that likes to chart on each and every order:  "Resident did not have symptoms.  Therefore, 911 was not called."  This is technically correct.  However, it does create a lot of unnecessary progress notes. 

Any thoughts on which is the best charting method? If you chart yes to calling 911 and you didn't, it could be argued that this was falsification of documentation.  However, if you write 911 was not called every time you don't call 911, you're creating a lot of progress notes that don't need to be made. 

[Sour Lemon]

I despise "duh" charting, but people are going to do what they're comfortable with. Among my favorites are "sleep notes" for behavioral health patients. We chart the number of hours they sleep, and that's fine, but some people feel the need to add a narrative note specifying that each patient was not in respiratory distress. Uh, okay. I assume you would have done something about it if they had been.

[caliotter3]

When charting TAR notes, I have always charted only when I do something or note something, unless the entry is of significance.  We had a quite detailed area regarding the poop function.  A poop surveyor could build quite a complete poop diary based on reading our poop entries.  Now THAT is significant.  FYI TAR entries - nothing, if it is there I will read it and be reminded, I certainly am not going to take the time and effort to address it every time I read it.   My seeminngly 'duh' (electronic) hourly sleep entries in home care have a primary function (for me) of proving, by way of their electronic signature, that at least one time each hour I am awake on duty.  Otherwise, who cares until the morning?  That's what I say.

[TheMoonisMyLantern, ADN, LPN, RN]

Are putting such orders really necessary in the TAR? Some times things like that get added to ours and the managers will evaluate and remove as needed. If it is a standing order to send the resident to ER if certain conditions are met it shouldn't have to be documented every shift.