Documenting Others Meds

xoemmylouox, ASN, RN · Dec 8, 2015

Is there a reason for documenting this in EMR? Surely they had you guys using paper charting in the meantime. That information needs to be "scanned" into the EMR chart. Documentation needs to simply refer to this. At least that is how we have handled things in the past.

Mr Sacdiff · Dec 9, 2015

Everything is documented on paper. I'm told it has to be duplicated in the EMR for billing purposes. We are now being told there will be hell to pay if we do not do it.

quiltynurse56, LPN, LVN · Dec 9, 2015

I think that each nurse should go back and input the meds the gave. You did not give them so you shouldn't sign off that you did.

Karou · Dec 9, 2015

No. You don't know these other nurses gave the medications they signed off for on paper. That's falsification of documentation. I would refuse to do that.

I don't understand why scanning the original downtime paper documents into the EMR isn't sufficient. Whoever is demanding this be done can do it themselves.

iluvivt, BSN, RN · Dec 9, 2015

In the Electronic Medical Record you can document that someone else administered a medication. You are NOT documenting that you gave it . but you are documenting that someone else did. This often happens during urgent procedures or surgery when it is not realistic or feasible for the other person to do it.

In your case it sounds as if all they are asking you to do is to input data into the sytem. There should be a mechanism to state that is what you are doing. If that is not in place and by documenting it will appear as if you administrated the medication then I would never do it.

Karou · Dec 9, 2015

In the Electronic Medical Record you can document that someone else administered a medication. You are NOT documenting that you gave it . but you are documenting that someone else did. This often happens during urgent procedures or surgery when it is not realistic or feasible for the other person to do it.
In your case it sounds as if all they are asking you to do is to input data into the sytem. There should be a mechanism to state that is what you are doing. If that is not in place and by documenting it will appear as if you administrated the medication then I would never do it.

We have that option as well with our EMAR, but I interpreted it differently...

I thought the "given by other" can only be documented if you witnessed the "someone else" give it. Like if a surgeon did a bedside I&D using lidocaine, then the nurse could document "given by other" when she witnessed the administration, and add in the comment "given by XYZ physician during bedside I&D, witnessed by this nurse". I wouldn't want to document "given by other" because truly, I don't know if the medication was administered if I didn't witness it...

The whole thing sounds like a clerical/billing issue that nursing staff shouldn't have to deal with.

allnurses Guide · Dec 9, 2015

My workplace currently underwent a downtime where our electronic medication record was unavailable. Now that it is back up two days later our supervisor is requesting that we chart medications that we did not even administer. I been told by seasoned nurses that this is illegal. Can anyone show me the proof of this. I do not like the idea of charting medications that I never gave or never witnessed being given.

If your computer system is like our you can enter a progress note such as Late Entry: Due to computer downtime this medication was administered by etc...

hppy

Editorial Team / Admin · Dec 10, 2015

We have two options that would be applicable: Given by another nurse or Given during downtime. As long as the paper charting was scanned into the EMR, I would be okay transcribing the paper MAR as either of those two options with the comment "given by Nurse X, documented per downtime protocol".

In fact, when our system is down, it is the job of the unit secretaries to enter the entire OR record from paper. Then, the nurse who circulated the case verifies the record as correct with a note "transcribed from downtime documentation by XYZ, verified by R. Nurse".

Mr Sacdiff · Dec 10, 2015

That's about what was done. Except they got rid of our secretaries so the nurses did it.

Thanks for all the responses.