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Documenting injection the MD gave

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I caught up on this thread just now and I'm eternally grateful that my last stint in the ER as a nurse had paper charting and not an EMR system.

I worked for about 9 months last year in our outpatient med department. I did wound care, gave IV meds, blood transfusions, etc. The EMR system was difficult to use. Especially the med admin part. :sarcastic: I loved being able to start IV's and other nursing duties not usually found as a hospice RN but that computer simply got in the way of me and my nursing objectives.

I still wouldn't chart something I didn't see given.

COB or dinosaur . . . that's me. ;)

(Edited to add . . . why not fix the EMR system so the providers CAN chart meds??)

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I would document that I was advised by the MD that he administered x mm of x drug im x site.

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Just to play devil's advocate here,...I am a new NP (1 yr) and work in ED. Recently during my shift, we were very busy with several critical patients in the department. The nurses were overwhelmed with trying to get two patients ready for the cath lab, one elderly DNR patient on CPAP actively dying, as well as two septic infants that needed to be flown out. While I am currently in the role of NP, I am a very experienced ED RN and completely capable of helping. We had 4 hall bed patients that needed lines, labs, fluids and meds. I started the IV's, hung the fluids and gave nausea and pain meds. Then I realized that our EMR does not give me an option to mark these things as completed or even a place to chart details of my lines! I did place a free text note in each chart of the tasks that I had personally completed, but the nursing staff had to "officially" chart completion of the orders. I can't see the "nurses" side of the charting as a provider, I had no idea! It was taken care of, and everyone was happy for the assistance, but I'm not really sure how the EMR required them to mark these orders as complete.

This is exactly what I was thinking. I work in the ED and I know our provideres can't chart meds as adminsitered. I will pull the med and give it to the provider, on our drop down list it says "Admin. by Provider" and I will add a comment (Medication given to XXXX MD/DO/NP/PA by RN for admin. during procedure [RSI, lacercation repair etc.]) I don't make them draw it up in front of me necessarily because there isn't always time to do that in the ED but if they need to waste the remainder of a conrolled substance and they want me to witness it then I need to see it removed and wasted.

!Chris

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I'm not sure if they can in our epic. The MD said he didn't know how to, I offered to show him, he said no, then he got someone else to do it. It was a depo-medrol injection. We, as the nursing staff, don't have a way to put it was given by xyz but can write in the comments. I am very possibly over paranoid but I was thinking in my head that he could have accidentally given the wrong med and then asked me to chart the right one, absolving him if the patient had issues after. Again yes, paranoid, but that was only the second time I had worked with him and I know he would not be sticking up for me at the end of the day if there were to be a problem.

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In general nurses don't document what providers do. However if for some reason a provider gave an injection and asked me to enter it, I might and just put administered by Dr. X so it would be correctly entered (e.g., an immunization). You aren't being asked to enter something you didn't do, you're just being asked to enter it was done. For the most part, I'd just put it back on the provider. Say, "hey this is where you can document your injections in our electronic medical record." Nurses carry out doctor's orders, however we are not their subordinates. But in some clinical practices there is still a bad habit of nurses acting as medical assistants. Help with provider documentation should be done by medical assistants, scribes, or clerks not nurses.

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As a nurse who worked in a Urgent Care setting, I would not have documented the injection. The physician could do it himself. I worked at a Urgent Care that is in roughly 20 states, and I would get travelers all the time. I didn't do it, I didn't draw it up, and I didn't watch it administered. I'm not going to document anything on it.

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Well, I routinely give phials of lidocaine to the providers after having scanned them into the MAR. I simply make a note: "Phial to provider at bedside."

Likewise, in a code or a trauma during which I'm scribing, I chart what's called out by whoever is giving it.

And during RSI, I chart how much med the provider says they gave.

The docs give the meds in your RSI's? Are there two docs present? Curious because I know things vary place to place so if the doc is giving the med I was wondering if another doc is intubating, or if you're scribing while another nurse gives the meds?

Your scenario reminded me of another situation though where it's common to for a nurse to chart meds they didn't give. In our Codes and Trauma situations there is a designated scribe and they will and are expected to chart the meds. Not that they gave it, they chart the nurse or doc that gave it and the amount said and time.

The scribe does not pull up the med or verify the med. But this is expected in their roll and everyone signs off on the code and trauma sheets if paper charting or electronic if that hospital has upgraded to the Trauma and Code Narrator.

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In general nurses don't document what providers do. However if for some reason a provider gave an injection and asked me to enter it, I might and just put administered by Dr. X so it would be correctly entered (e.g., an immunization). You aren't being asked to enter something you didn't do, you're just being asked to enter it was done. For the most part, I'd just put it back on the provider. Say, "hey this is where you can document your injections in our electronic medical record." Nurses carry out doctor's orders, however we are not their subordinates. But in some clinical practices there is still a bad habit of nurses acting as medical assistants. Help with provider documentation should be done by medical assistants, scribes, or clerks not nurses.

As stated in this thread, some EMR's are set up that the doctors can not chart the medications. It has to be charted by the nurse or the medication continues to show up like it wasn't given. Which is why there is usually an option for the nurse to chart it as given by the provider. Which in these cases it has nothing to do with the doc not being willing. I have met so many docs that would gladly get their own lidocaine and suture kits and so on and chart it all. But they can't pull meds or get in the supply pyxsis so they have to wait on us for a lot of things. Frustrating for us and them but apparently administration has their reasons for it. :sarcastic:

Edited by ~Mi Vida Loca~RN

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I'm not sure if they can in our epic. The MD said he didn't know how to, I offered to show him, he said no, then he got someone else to do it. It was a depo-medrol injection. We, as the nursing staff, don't have a way to put it was given by xyz but can write in the comments. I am very possibly over paranoid but I was thinking in my head that he could have accidentally given the wrong med and then asked me to chart the right one, absolving him if the patient had issues after. Again yes, paranoid, but that was only the second time I had worked with him and I know he would not be sticking up for me at the end of the day if there were to be a problem.

This situation might be very different then what some of us are talking about we experience in the ER.

Who drew up and gave him the med? Or do your physicians have access to meds?

I would feel differently if we are talking about a situation where a doc came up to me and said "Mi Vida, I just gave Ms. Jones 1gram of Rocephin, I need you to chart it" and I had no knowledge of them giving the med, who got the med, how much was given, etc. etc.

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Just to play devil's advocate here,...I am a new NP (1 yr) and work in ED. Recently during my shift, we were very busy with several critical patients in the department. The nurses were overwhelmed with trying to get two patients ready for the cath lab, one elderly DNR patient on CPAP actively dying, as well as two septic infants that needed to be flown out. While I am currently in the role of NP, I am a very experienced ED RN and completely capable of helping. We had 4 hall bed patients that needed lines, labs, fluids and meds. I started the IV's, hung the fluids and gave nausea and pain meds. Then I realized that our EMR does not give me an option to mark these things as completed or even a place to chart details of my lines! I did place a free text note in each chart of the tasks that I had personally completed, but the nursing staff had to "officially" chart completion of the orders. I can't see the "nurses" side of the charting as a provider, I had no idea! It was taken care of, and everyone was happy for the assistance, but I'm not really sure how the EMR required them to mark these orders as complete.

I think our charting system is similar. Dr & PA (we don't seem to have any NP in the ER anyways) don't have access to the pixis. As a consequence we have to pull any Med that they administer. Such as lidocaine for stitches. We pull it and document as "given by other" there is a space for free text where we can add whatever we wish.

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This situation might be very different then what some of us are talking about we experience in the ER.

Who drew up and gave him the med? Or do your physicians have access to meds?

I would feel differently if we are talking about a situation where a doc came up to me and said "Mi Vida, I just gave Ms. Jones 1gram of Rocephin, I need you to chart it" and I had no knowledge of them giving the med, who got the med, how much was given, etc. etc.

That was exactly the situation. I was like "Um, say what". The meds are behind a locked storage door we all have access too. There isn't a pixis or anything of the sort. I had no details, just that I needed to got to the MAR and chart it as given.

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