HH nurses and others...Argghhh I need some charting help!

[DutchgirlRN, ASN, RN]

I saw a patient today who has a PT/INR order 3x week times 2 weeks. Her INR was >7.5 so it wouldn't register. I drew her blood for a stat PT/INR and took it to the hospital lab. The result was the INR was 9.36.

I called the doctor with a critical value. (no brainer) well this doctor was pissed off. Who in the h*** gave you an order to draw her blood? I told him it was our office protocol when a INR registers over >7.5 He said who told you to do her PT/INR today in the first place? I said it was ordered 3 x a week times 2 weeks. He said "no it wasn't", he said how long does it take for an INR to reflect a change in the coumadin dose? I said approx 3 days. He said "NO wrong again the answer is 2.5 days. What a jerk.

He said I think that INR of 9.36 is an error and is an erroneous result and I want you to repeat it tomorrow. I asked what about the Coumadin. I would like to call the pt and tell her not to take it tonight. He said "so you want to be in charge". No I want to do what's right for the patient. He said "let me talk to your supervisor".

He tells my DON that the patient had been at his office on Monday and that her INR was 7.0 per venipuncture and that his office staff had called the patient on Tuesday and ordered that she not take the Coumadin that night, then resume it the following day and repeat the PT/INR in one week. I called the patient who said "no one ever called me" I didn't know the result was 7.0 on Monday or I would have told you when you were here. I never talked to them".

I called the office and asked to speak to his nurse who I asked RN or LPN? Ummmmm M.A. Okay, tell the doctor that I will repeat the PT/INR tomorrow morning. The patient states she didn't receive the previous order and I advised her not to take the Coumadin tonight and the M.A. said ok I'll tell him and agree with her not taking the Coumadin tonight.

Anything in particular that I really need to include in my charting? Should I chart the doctors attitude (in a nice way)? Thanks I could really use some feedback. I know I did the absolute right thing but want to make sure Ichart everything correctly and chart everything that I need to.

[camrave]

That MD sounds like a jerk. Just make sure to include in your documentation what the patient told you and the conversation with the MD and MA. It probably won't do any good to put in the MD's attitude. You did everything right because you followed the orders that were given to the agency. After the patient was admitted were these orders confirmed, because sometimes I find the hospital sends the patient home with different set of orders then the MD that will be following their care. I've had this happen a couple of times. We usually draw PT/INR's on Mon and Thurs or once a week depending on the MD and the results. One pt we had came home with PT/INR to be drawn Mon, Wed, and Fri which I called the surgeon and it was supposed to be mon and Thurs because if there was a change in the dose it wouldn't have taken affect until at least 2 days later.

[steelcityrn, RN]

Maybe I missed something here, did you say that the physician wanted the coumadin held tuesday night and then resumed(at what dose?), then rechecked in one week? Why did you then call the office and tell them you would recollect it in the am? As far as charting, I would chart what the physician wanted, chart the patient states "was not called with coumadin orders from Dr ???", then drop it. I would write the order as he stated and collect her pt/inr in one week.

[DutchgirlRN, ASN, RN]

Maybe I missed something here, did you say that the physician wanted the coumadin held tuesday night and then resumed(at what dose?),

Her usual dose of 5mg Q Evening

then rechecked in one week?

Yes, unbelieveable!

Why did you then call the office and tell them you would recollect it in the am?

Dr. Jerk wanted me to redraw tomorrow because he said the lab results were "false and erroneous"

As far as charting, I would chart what the physician wanted, chart the patient states "was not called with coumadin orders from Dr ???", then drop it. I would write the order as he stated and collect her pt/inr in one week.

I would think that would be dangerous to the patient. If this were my Mother would I want her to continue her Coumadin knowing her INR was 9.36 and not recheck it for a full week? No Way! I have to do what I can live with.

[DutchgirlRN, ASN, RN]

That MD sounds like a jerk. Just make sure to include in your documentation what the patient told you and the conversation with the MD and MA. It probably won't do any good to put in the MD's attitude. You did everything right because you followed the orders that were given to the agency. After the patient was admitted were these orders confirmed, because sometimes I find the hospital sends the patient home with different set of orders then the MD that will be following their care. I've had this happen a couple of times. We usually draw PT/INR's on Mon and Thurs or once a week depending on the MD and the results. One pt we had came home with PT/INR to be drawn Mon, Wed, and Fri which I called the surgeon and it was supposed to be mon and Thurs because if there was a change in the dose it wouldn't have taken affect until at least 2 days later.

The agency is thinking that the 3x week order for PT/INR came from the hospitalist and not the attending but that doesn't make them any less valid does it? I'm not being flippant I really need to know. The hospitalists discharge orders should be as valid as the attending orders?

It took me 3 hours to figure exactly what to chart. (I'm glad I get paid charting time!) As far as the doctor I just charted that he requested that SN redraw PT/INR in A.M. because he felt that the 9.36 INR result was an error and was erroneous. Also that he stated he had not ordered another PT/INR to be done for a week and asked this SN who gave the authority to do the PT/INR today. SN replied our orders state PT/INR 3 x week times 2 weeks and our protocol is to follow up with a stat venipuncture PT/INR when the fingerstick INR >7.5 and that he asked to speak with my supervisor and I complied. The charting is all on PDA so I didn't sign it yet. I'll let my DON read it before I sign my name. Thanks for your help.

[DutchgirlRN, ASN, RN]

The patients venipuncture PT/INR today was 6.2. The doctor ordered the coumadin be held one more night and then restart coumadin at half her usual dose and repeat PT/INR on Monday. When I talked to the doctor he was very very nice. He must of had a really bad day yesterday and he sure turned my day into a bad one as well!