Documenting

Nurses General Nursing

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Specializes in Cardiac.

Do you always document what the physician tells you in quotes? For example we have a physician that often at night will say "leave the patient alone and don't call me anymore." This is pretty much the reply even when calling with something critical like an elevated troponin.

Other times this same physician will say things like are you stupid? Or are you even a nurse? This is not necessarily a problem between this physician and I, as he's only done this to me once, but happens frequently to a lot of nurses on our unit regardless of skill level.

I was always taught to chart what the physician says in quotes to cover my own butt. There has been an issue lately though where management has been telling the nurses not to chart these things. Advice please?

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Specializes in Emergency.

Verbatim statements are always in quotes as far as I'm concerned.

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Quotes are your friend. I use verbatim quotes all the time, especially if it's "don't call me again about this patient".

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Specializes in Pulmonary, Lung Transplant, Med/Surg.

Sounds like management knows this guy is an issue and they don't want it documented. Keep documenting in quotes because God forbid you're in court next to this jerk you have something I stand on!! Good luck!

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Specializes in Cardiac.

That's what I've always thought and been taught. Been a nurse for almost 14 yrs. what kinds of things that the physician says to you would you not chart? Like sometimes he will just say are you stupid and hang up on someone.

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Specializes in Orthopedic, LTC, STR, Med-Surg, Tele.

That's really obnoxious and unnecessary on the part of the doc. I would put everything in quotes, I'm guessing he doesn't talk to management that way.

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Specializes in Pulmonary, Lung Transplant, Med/Surg.
That's what I've always thought and been taught. Been a nurse for almost 14 yrs. what kinds of things that the physician says to you would you not chart? Like sometimes he will just say are you stupid and hang up on someone.

If that's what he's saying then that's what I would chart, honestly. Write why you called him and what his response was.

ALSO I would get together with your coworkers and start a document of your own with dates, times and quotes. When you have a page full go as high as you can with the evidence. He needs to be out in his place. If you guys let him get away with it he'll keep doing it. You're more likely to get results if you have solid evidence!

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I would chart what the doctor says about the patient, not directly to you. So if doctor says, "you're really calling me about that? Are you stupid? Only call me if his blah blah blah lab is above X." I would chart only their last sentence. The beginning sentences are not about the patient.

The other things? I would pass on a note to your manager or DON with those quotes and express your concerns.

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Specializes in Acute Care Cardiac, Education, Prof Practice.

As the above poster said I usually only document things pertinent to the patient. So if he says "Hey stupid, leave the patient alone and don't call me" then I would put MD requests no further calls on patient status, or something like that. Anything derogatory or belittling needs to go through channels other than the patient record. If the patient dies on the shift, then it is documented that he informed you not to call anymore, but anything personal he said to you, about you, can cause issues and holes with lawyers should it go to court. Or at least that is how I was taught.

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Specializes in PCCN.

a co worker had this happen recently- pt had a HR of 165 sustained. Cardiologist said " thats ok, dont call me anymore for that.

Some docs are such pompous arrogant jerks.

I'm sure management is just kissing his butt cause aren't we supposed to be taking care of the "im always right" customer- ie the MD

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As some other people have suggested, I would chart the doctor's response in neutral language while of course making sure that his refusal to act was clearly conveyed. I would write a report, including the conversation verbatim and note time and date for future reference. I would keep a copy of this version and send one to management.

I would do that each and every time this doctor steps out of line. I would encourage my co-workers to do the same.

It sounds like management are well aware of the existing problem and want to employ the time-honoured "bury their heads in the sand" method.

I find it utterly unacceptable that this doctor says things like "are you stupid?". The fact that he's only done it to you once but numerous times to others doesn't in my opinion mean that you should accept this behaviour. Once is one time too many.

I'm not sure how things work in an American hospital, I'm Swedish. We have " rapid response teams" 24/7 (usually an anesthesiologist and a nurse anesthetist) that all floor nurses can call if a patient's vital signs go south or if the nurses' gut feeling says that something is going on with the patient. Everyone is encouraged to call them when in doubt. Do you have any similar resources at your hospital?

I'd be very concerned if the patient's primary physician refused to respond to what I considered a serious change in the patient's status.

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