I like psych but...

[BookwormRN]

I really fell in love with psychiatric nursing during nursing school. However, I accepted a position on the med/surg floor where I'd worked as a CNA and Nurse Tech. (We don't have a psych/behavioral health unit)....this job is only 1.5 miles away from home.

About a year ago, I interviewed for and was offered a job on a locked psychiatric hospital unit...did not accept the position due to the hours (did not like the shift and the fact that it was full-time...plus it is 1 hour from my home.)

Same unit called and offered me an occassional position. I accepted and started a couple of weeks ago-doing orientation on my days off from my primary job.

I'm going crazy (pun intended!) right now! I really do like the unit and the patients. Not so crazy about the way some things are done there, however, regarding charting and the legalities of it. I was told by a couple of nurses, "This is totally different from med/surg...that's the way we do it here." For example: In staffing, the Dr. will state a change in a Pts level of activity. The RN will then chart "T.O. Dr. so and so/jane doe, RN"

Hello! It was a verbal order....You did not call the Dr for that. I know it is a technicality, but come on! Joint Commission is trying to get away from verbal orders, but they didn't mean for us to lie, they want the physicians to write the orders.

THEN, when the Social workers get things in order for discharge, the RNs will write the DC order and sign "T.O. Dr so and so/jane doe, RN" Now mind you, this is a medical Dr from a clinic that hasn't even been in to see that pt that day, let alone given a T.O. for discharge. WHAT?????????? Yes, this is the medical group that does see the Pts for medical issues and they do come in, but if they've not given the order, how can you legally write it??? I was then told that the Pts chart would go in that medical groups mailbox, and "The Dr will sign the order tomorrow that he doesn't even know that he has given." !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! UGH!

I just don't think I can work like this. Am I justified in my thoughts? I think I'll be going in to have a chat with the manager tomorrow and express my concerns. After all, in the court of law, if something happens, it's my butt on the line if the MD says "She never called to get that DC order!"

Thanks for letting me vent. I sure do appreciate any and all feedback!

[NurseCard, ADN]

Yes, I would definately say that you are justified in being concerned. No, you aren't supposed to write an order that you weren't given. Yes, you can get in big trouble for doing that.

The ONLY thing that I can offer is this... well okay, let me speak directly from my own experience. I worked in a psych hospital, not a psych unit that was part of a "regular" hospital. The patients there were not ever even SEEN by a medical doctor/general practitioner/whatever, unless there was an acute medical condition, or rather, something that presented itself while the patient was in the psych hospital. If it was anything too serious, the patient would be sent off to the medical hospital for treatment.

When the time came for a patient to be discharged, it was generally and fully the decision of the PSYCHIATRIST, the social worker, the psychologist.. the members of the patient's "treatment team". A medical doctor rarely even had any say as whether or not the patient could be discharged, because the patient wasn't there primarily for medical treatment.

I'm probably not really addressing the point of your post though... what I'm trying to say is that, maybe the medical record has to show SOMETHING to the effect that the medical doctor who saw the patient while the patient was in psychiatric care, feels that it is OK for the patient to leave the hospital. And maybe because psych tends to be a more laid-back field anyway, the staff feels that it is OK to just write a telephone order stating that yes, Dr Medical discharges this patient, instead of going to the trouble to call that doctor at the clinic, knowing that that doctor is not going to have a problem with this particular patient being discharged from psych care.

Am I making ANY sense? Probably not.

Bottom line though, is that you do feel uncomfortable writing telephone orders that you didn't actually take, or at least take over the telephone. Also, perhaps a better system for discharging psych patients at your facility, overall, needs to be put in place. So, talk to your manager about your concerns. You are right to have them.

I was just offering my own insight into the situation.

[JCLVN67]

Psychiatrists ARE medical doctors.They went to med school and had to work as residents before becoming psychiatrists. I've seen psychiatrists who still "know their stuff" when it comes to medical issues.But then again I'm sure they are behind the times in current trends and techniques in general medicine. Just my two cents.

[Is it 4 me]

Obviously I’m not sure what the legalities involved are but I can tell you that psych is a far cry from any med/surg setting. I work in a locked psych unit that is part of a small medical center and as my supervisor who is a long time RN put it, ‘we are the red-headed, retarded, one armed, paraplegic, step-child of the hospital.’ Meaning we get all the hand-me-downs and things are sometimes lax, particularly documentation and med h&ps for our patients.

While my main focus is, as it should be, on the patients care and safety my second focus is on documentation, I tell new staff we live and die by our documentation. We are not licensed, but I am certified and it gives me a little more money and just a smidgen more of respect from management. But even w/o the certification I’d not want to be in a position where I have to swear in a court of law that what I documented is accurate if I’m unsure. I imagine that is multiplied 100 fold for you with regard to your license. Our docs do give verbal and telephone orders that the nurses record as T.O. but I can’t think of an instance where anyone but a M.D. has given a d/c order, or where an order was written by someone else then signed a few days later. That’s very, very scary to me…what if the doc forgets, or didn’t mean the order to be what the nurse wrote? Or, worse case it somehow gets overlooked and the doc NEVER signs it? I’d talk to someone about it, it is a legitimate concern and maybe it’s time someone who can make a change woke up and smelled JCAHO.