My facility has recently changed to electronic charting from paper charting... Consequently, there's no easy way to send a message to a doctor for advice without making it a permanent part of the chart in what's called an "event note" that becomes a permanent part of the patients chart... Which the patient, pt's family, & attorneys could have access to if needed. Before I could just stick a post-it on the front of the chart to say "what do you want me to do about xyz?" My question is: How formal or how professional should those event notes be? For example, today I had a patient refuse to have his Foley catheter removed when I told him there was an order to remove it. At the end of my shift I put in an event note that said "Patient refused Foley catheter removal. Patient stated he is unable to urinate on his own & is unwilling to attempt to use a urinal or go to the bathroom. Please advise." Since everyone who cares for that patient has access to his chart and this note, one of the other nurses read what I said and said it sounded "stuffy" but how else should I tell the doctor what's going on & ask for a plan of action with out saying "This guy is lazy & says he doesn't want to get up & pee. What should I do?" ...And I won't be back to work for 5 days, so it's not really ME who needs to know what to do. Also, I want my documentation to be clear, concise, consistent, and professional enough that I wouldn't be embarrassed to defend it in court, if the need ever arises. How would you communicate this info & ask for advice??
