Documenting injection the MD gave

BrnEyedGirl, BSN, MSN, RN, APRN · May 7, 2017

Just to play devil's advocate here,...I am a new NP (1 yr) and work in ED. Recently during my shift, we were very busy with several critical patients in the department. The nurses were overwhelmed with trying to get two patients ready for the cath lab, one elderly DNR patient on CPAP actively dying, as well as two septic infants that needed to be flown out. While I am currently in the role of NP, I am a very experienced ED RN and completely capable of helping. We had 4 hall bed patients that needed lines, labs, fluids and meds. I started the IV's, hung the fluids and gave nausea and pain meds. Then I realized that our EMR does not give me an option to mark these things as completed or even a place to chart details of my lines! I did place a free text note in each chart of the tasks that I had personally completed, but the nursing staff had to "officially" chart completion of the orders. I can't see the "nurses" side of the charting as a provider, I had no idea! It was taken care of, and everyone was happy for the assistance, but I'm not really sure how the EMR required them to mark these orders as complete.

~Mi Vida Loca~RN, ASN, RN · May 7, 2017

It's pretty common in the ER's I have worked in to document some of the meds for the doctor. The doctor doesn't have the ability in our EMR to do it. The most common one I encounter is lidocaine for suturing or dental blocks. I don't sit in there and watch them administer it, or if they have to re-administer more. The docs will write their notes but the way our EMR is set up the order has to go in to pull the med (for the most part obviously there are situations where we can override) and so the med has to be documented. We have an option to simply put "administered by physician". I have never had a problem doing this. I don't chart that I saw it, I don't chart where or how much. I simply select the box that says administered by physician.

However, once in a while the meds will be controlled substances, like pushing propofol. Again, I have to pull it and it has to be charted but in these cases I won't sign off unless I was present when it was given. There isn't a situation where the doc would be alone administering these meds so there should be someone that saw and can document.

Any other meds (which I haven't encountered) I would say med pull and given to physician (including name obviously) and chart what the doc said he gave.

MunoRN, RN · May 7, 2017

Every EMR has some way of charting, either as a drop down box or at least a comment, that a medication you're charting as given was given by someone else, "MD reported injection of such and such was administered by MD". I wouldn't have any problem charting that an MD reported he gave a med.

Neuro Guy NP, DNP, PhD, APRN · May 7, 2017

Like another poster wrote, at most of the hospitals where I am credentialing, the medical staff does not have the ability to document they gave a medication because we don't scan or administer medications, that's a nursing function. So generally, the nurse will get our name, scan the patient and medication as usual, as tag "administered by other" and then find out name in the system. At that point, the administration will pop up in our "to sign" section in the EMR and we will sign it as in the same manner a verbal order, but instead it will be recorded as our acknowledgement that we gave the medication.

Example drugs where this occurs, is lidocaine for procedures, certain IV push vasoactives outside of the ICU, cardioversion, etc.

K9lover, ASN, RN · May 7, 2017

Is this a wise thing to do? I work for an urgent care, we have Dr/PA/NPs rotating constantly, hardly work with one more than a few times. An MD gave an injection he ordered and wanted me to document it. I didn't see him drawing it up or administering it so I wasn't at all comfortable signing off on it and I declined to do so. Of course the MD was miffed but you would be shocked at the amount of providers who cannot correctly give an injection and I didn't want my name on that. He said I could type in the comments he administered it but if a problem were to arise, its his word vs mine. Was I in the wrong? I would never do it for another nurse but was unsure if same goes for the providers...

You were right. I used to be more generous about this sort of thing 'back in the day' but it has been awhile...

SaltySarcasticSally, LPN, RN · May 7, 2017

Thx for the responses. We use epic so I'm going to check into how I could chart this in the future without signing my name off as looking like I did it. It just made me uncomfortable and have never had any provider ask me to do that in my 8 years as an LPN so was a bit weary.

JKL33 · May 7, 2017

My experience has been the same as Mi Vida Loca, above. None of the few EMRs I've worked with have given medical staff the ability to document medication administration, but all three have had one way or another that the nurse could choose to make note of it; if nothing else, even a brief narrative note can be made. I would not be comfortable documenting it in a fashion that makes it appear that I administered the medication myself nor one that would let someone assume I am verifying that it was indeed given as stated. In your specific case, if the EMR didn't provide a better option I would simply make a narrative - "writer informed by Dr. X that s/he has administered ____mg ____med _____route".

I'm not a fan of common current practice where nurses are expected to pull, and/or scan (document) and/or waste medications that a provider will be administering. But...for now that's a battle for another day. :-/

~Mi Vida Loca~RN, ASN, RN · May 7, 2017

Thx for the responses. We use epic so I'm going to check into how I could chart this in the future without signing my name off as looking like I did it. It just made me uncomfortable and have never had any provider ask me to do that in my 8 years as an LPN so was a bit weary.

I have used this feature on EPIC. but having EPIC at many different hospitals I have learned that it's very customizable (is that even a word?) lol so not sure if yours would have it for sure. The EPIC we use in the ER is also different than the floors. But I would think the medication admin part is all very similar.

What was the medication? Curious if it's one more common for us to chart.

TriciaJ, RN · May 8, 2017

Would it be inappropriate to make a nursing note along the lines of
X MD ordered me to chart his administration of Y med to patient. Informed MD I cannot do that as it's a violation of hospital policy and the state nurse practice act.

Yes, it's inappropriate. It provides no information pertinent to the patient. A medical chart is not the place to front street anyone or air your grievances.

Ruby Vee, BSN · May 8, 2017

Thank you, Only being a student currently I was unsure if something like that needed any documentation and where one would put it... I will keep this in mind should the need arise in the future...

That sort of information does not belong in an incident report unless there was an actual incident. The fact that the MD gave a medication DOES belong in the chart, and usually THEY won't put it there, so we have to. Suppose the MD gave 200 mcg of Fentanyl for a procedure and NO ONE charts it. Then off you go to lunch and the patient wakes up and asks for some pain medicine. That 200 mcg. had better BE in the chart because if it isn't and the next nurse gives it, there could be some serious respiratory depression. Suppose the physician gives a medication and you won't chart it and the physician won't chart it and someone else comes along (the next shift, your lunch relief, the nurse who happened to be passing the room when a consultant passes by and wonders why that vital drug wasn't given and wants it given right now). If it's not in the chart, it hasn't been given.

Why have a power struggle over something that is so easily taken care of. Just chart it as given by MD, put their name in and it's charted and out of your hands.

bgxyrnf, MSN, RN · May 8, 2017

Well, I routinely give phials of lidocaine to the providers after having scanned them into the MAR. I simply make a note: "Phial to provider at bedside."

Likewise, in a code or a trauma during which I'm scribing, I chart what's called out by whoever is giving it.

And during RSI, I chart how much med the provider says they gave.

ruby_jane, BSN, RN · May 8, 2017

I didn't see him drawing it up or administering it so I wasn't at all comfortable signing off on it and I declined to do so. ..

Good job. What kind of charting system do you have? Is it burdensome for the provider to go in and chart this? Or is the provider not willing to spend the five minutes to do it?