About charting... - page 2

I was reading an article about a malpractice case that made our front page here. An md was being sued. He claimed he told a nurse to do something stat. It wasn't done stat and that resulted in a... Read More

  1. by   ceecel.dee
    Oh yeah.....tensions are high!

    But we are compiling evidence, and we'll see what "they" will do. Our DON is right there with us on this one!
  2. by   sbic56
    That's good! Nice to have that type of support from the DON...crucial in fact. Happy "paper" trails to you!
  3. by   renerian
    I have always been told I have excellent but LONG charting.

  4. by   Tweety
    Originally posted by angelbear
    Wouldnt my documenting that fact in the nurses notes back me up? I dont know how else I could prove that I let the appropriate people know of my concerns. This is becoming an issue in several situations and I just want to make sure I am covering myself. Thanks for your response.
    The courts love to see you use your resources and notify the higher ups of problems. The question would be if this problem warrented immediate action or is a note on the voicemail or the chart acceptable. If it is, then your charting that they were notified will help CYA. Also, is it written in your policies and procedures that notifying the person by voicemail is acceptable.

    It also wouldn't hurt to write an ending note, day shift nurse so-and-so notified and asked to followup on said problem since it's not an emergency.

  5. by   pickledpepperRN
    Originally posted by renerian
    I have always been told I have excellent but LONG charting.

    Once I documented looong quotes of conversations with a patient who didn't want to take his Q6 hour cardiac meds. He told me he would refuse anything I woke him up for.
    Called the MD who told me to chart the patient refused medication. I documented that I had asked him to use the call light if he awoke, then found his full urinal hanging on the siderail.
    This patient recovered but sued that he had not received his medications.
    That copious quoting saved the hospital from a law suit. They later found he had sued another hospital once before.
  6. by   MelRN13
    That's a great example spacenurse. I've been told that my charting is "too long." I just would like to cover all of the bases.

    I've seen pt's that were not charted on almost all shift. Maybe an entry at 0800, and again at 1500. Even if there are no changes, I still would chart "VSS, no acute distress noted. "
  7. by   cab631
    I would not rely on the voice mail thing. I don't know about anyone else, but i erase my voice mails after I note who called and about what. And I don't see where they would last very long. Most systems start knocking off old voice mails when they reach a certain point. And how do you know the person you left the voice mail got it? And what if the person who you intended the voice mail for got hit by a bus? ALWAYS tell somebody things like this in person. Even if you have to page them to get them. The other thing is--at our facility we have started writing VRB behind our names, after the RN, which means VERBAL READBACK. Jacho likes that, so we've implemented it in our hospital. It indicates that the order you received was read back to the MD who gave it to you.