Specializes in Cardio-Pulmonary; Med-Surg; Private Duty.
I'm surprised that your agency doesn't have a Task Record (like a MAR, only for tasks instead of meds) for things like equipment cleaning. Things like the days that trachs / vent circuits / suction canisters are to be replaced can be noted and initialed so everyone knows when they are due / when they were last done and by whom.
I'm surprised that your agency doesn't have a Task Record (like a MAR, only for tasks instead of meds) for things like equipment cleaning. Things like the days that trachs / vent circuits / suction canisters are to be replaced can be noted and initialed so everyone knows when they are due / when they were last done and by whom.
They do.
But many nurses still like to look at the composition books for a brief summary of the shift.
It could be writing something as simple as "Tom had an uneventful day with x2 loose BM,no seizures,redness on right side of neck under trach ties."
We call it a communication book. We used to have communication logs, but nurses ruined that. Then families and nurses kept communication books (spiral notebooks) to leave report or updates in. They must be kept because they are a legal document. Agencies hate them because of that and because nurses say things they shouldn't. I like them because sometimes there is a need to communicate with nurses that we may not see. And having a parent pass a message along means the parent might forget, or leave out info they think isn't important, or the parent could get confused and give the wrong message.
I guess we're getting off topic. But just wanted to share since it seems so many others haven't seen a communication book.
When I see that other nurses are not treating a communication book like the legal document that it is, I will refuse to put any entry in that book. Several nurses think it is a place to call co-workers non-complimentary names, or to give the world their contact info, to make plans with others for social occasions or to sell their Mary Kay, or to write things that are obviously of interest to a client preparing for a lawsuit. Information from the clinical supervisor fails to correct the way they treat the book. They do not need to listen to the clinical supervisor. I've written before about the client who ripped a page out of the book and yelled at me about it. I was already aware of the family's pending lawsuit. When I talked to the supervisor, the response was, "oh, well, they aren't suing the agency!" Just what did she think the page was torn out of the book for?" You have to be very, very careful to watch communication books and their contents.
Weird....in one of my agencies,the parents around here keep the composition books when no more pages are available.
One of the mother's on one of my cases buys the composition books.
When I worked a private duty case, the mother kept a log. Actually, the primary nurse was the one who initiated that log. When the agency is staffing a case, the communication book is part of the legal medical record and is turned in to the agency when filled up. If the agency is not doing this, it is their peculiar policy, and not the norm.
I guess since Mom is buying the composition book she thinks it belongs to her.
When the case opened it was upon the nurse who placed the field chart in the home to include the communication book and to make it clear to the family the purpose of the book. If the mother wanted her own log, she could place that too, but many nurses are not going to go out of their way to write in three different places for each shift.
Specializes in Complex pedi to LTC/SA & now a manager.
I guess since Mom is buying the composition book she thinks it belongs to her.
I would not stay on the case or at least have clinical nurse manager involved. At minimum I would not write anything in a parents book. This is a recipe for disaster. There are others who write more in the communication book than they do in the nursing notes.
brillohead, ADN, RN
1,781 Posts
I'm surprised that your agency doesn't have a Task Record (like a MAR, only for tasks instead of meds) for things like equipment cleaning. Things like the days that trachs / vent circuits / suction canisters are to be replaced can be noted and initialed so everyone knows when they are due / when they were last done and by whom.