Med Charting

[myac]

Recently at my hospital I received a letter stating I have 3 doses of Ativan that were "not noted" and was told if I don't straighten it out then I will be reported to the state.

I was was able to go back to that patients chart and print the mar that was scanned to their records, and find each order of Ativan for each dose I gave. I documented each administration and there are active orders for each.

Im not sure if it's because I'm at a teaching hospital and residents and physicians are still learning and CHANGE ORDERS BY THE MINUTE or if it's a glitch in the system.

Still makes me nervous.

And in another note has anyone ever forgotten to document a med? In the midst of all this I remembered I forgot to document a GI Cocktail in the mix of things. I verified in via computer and the time I pulled it is in the Pyxis but I don't think I hand charted ☹️

Tough being a new nurse and learning while having to babysit residents and be their safety net !

[Rivalicious]

I've once forgotten to document a PRN narc in the EMR but had signed it out on the paper sheet- no biggie, I just did it once I realized my error on the next shift.

I'll be honest that when it comes to non narcotic PRN's I've forgotten to document giving them a few times, because I have a heavy med pass and I am pretty liberal about giving them. A lot of my patients are non-verbal and can't communicate that they are in pain so if I see any sign of discomfort I'm throwing in some ibuprofen with their regular meds. I also pre-medicate my dressing changes and other potentially painful procedures. I have 48 patients to chart on every shift and I don't always have time to do the MAR as I go and will chart it after the fact, and occasionally forget. And yet I always somehow remember to pass on the info.to oncoming shift. Go figure.