Documenting injection the MD gave

~Mi Vida Loca~RN, ASN, RN · May 9, 2017

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.

Yea that would make me far more hesitant and uncomfortable. Especially if there was no reason why they couldn't just chart they gave it. Like there was no specific reason why it had to be done by you.

At the very MOST I might chart "Dr. X states medication Y administered in patients left deltoid"

BrnEyedGirl, BSN, MSN, RN, APRN · May 9, 2017

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.

Just curious, does your system allow the providers access to the Omnicell/Pixis etc? The system I work for does not allow this. I happen to have worked as an RN so I still have my access. If a patient needs lidocaine for a laceration the nurses must get it out for the provider. In the case of a laceration I as a provider make a procedure note that does include the "6 ml of 1% lidocaine with epi", but the nurses still have to sign off the order and they usually pull and draw up the meds for me, therefor they are tied to that med in the Omnicell. How is this handled in your system? There must be a way to chart a med used but administered by someone else. What do you do in a code situation or an RSI?

And why in the world was the provider giving the depo-medrol? Was it a trigger point injection, or a joint? Again if this is the case, did you have to pull it from the Omnicell?

bgxyrnf, MSN, RN · May 9, 2017

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?

It's hit-or-miss. Technically, nurses aren't to push the meds but we often do because there isn't a second doc there.

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.

Yep... in reality, this happens in a lot of our traumas because there's just too much to do and too many people doing it. It's a group of nurses who've worked together for awhile and know each other well. The doc calls out, "50 of fent," I grab the fent and push it after verbalizing, "OK, 50 of fent going in" at which point the scribe puts it into the chart.

bgxyrnf, MSN, RN · May 9, 2017

At the very MOST I might chart "Dr. X states medication Y administered in patients left deltoid"

Yep, nothing wrong with that. You're just charting what happened.

~Mi Vida Loca~RN, ASN, RN · May 9, 2017

It's hit-or-miss. Technically, nurses aren't to push the meds but we often do because there isn't a second doc there.
Yep... in reality, this happens in a lot of our traumas because there's just too much to do and too many people doing it. It's a group of nurses who've worked together for awhile and know each other well. The doc calls out, "50 of fent," I grab the fent and push it after verbalizing, "OK, 50 of fent going in" at which point the scribe puts it into the chart.

Same for us on the first although Propofol push is the only common one I can think of that we aren't allowed to push. But I know this varies states to states.

In the facilities I have worked in it wouldn't have even mattered if we knew each other well or not. It's expected for the scribe to chart the meds and who gave them.

If something were to happen the scribe would be covered. Like if the doc yells out 100mcg of fentanyl and the nurse repeats and gives it, you verify and chart 100mcg given at 2000 and after find out she gave 200mcg instead, you would not be faulted. Our charting via EMR or Paper though there is a spot where you mark which nurse gave meds so you're not charting you gave it yourself. I would assume this is pretty standard most places though. At least I would hope it would be. Pretty sure docs would not appreciate the scribe stopping the RSI to go verify the med and stuff. lol

bgxyrnf, MSN, RN · May 11, 2017

In the facilities I have worked in it wouldn't have even mattered if we knew each other well or not. It's expected for the scribe to chart the meds and who gave them.

Same here.

I was actually envisioning other scenarios in which two nurses are tag-teaming rather than a code or trauma resuscitation with a designated scribe. We've often charted meds as given or lines started without indicating that it was actually done by another nurse.

I think the ED often operates somewhat differently than the units or the floors. We don't have a problem receiving a syringe from a teammate and pushing it, at least once the trust has been established by working together in some crazy circumstances.