The unit always comes up with new forms for us to fill out, some that make me uncomfortable and some that take up my time & annoy me - BUT ALL OF WHICH are NOT part of the legal chart.
One of these forms is a hand-off sheet, were the nurse highlights info about a patient, and initials it with the nurse from the next shift. When something goes wrong, the management immediately goes to the hand-off to check . For instance, if a vanc through is missed and they nurse blames the previous shift for not reporting
I personally refuse to fill out this form because I believe it sets you up for trouble. It's not in our hospital policy to fill out such a form.
I told this to another nurse, and her response was, "that's why they have everyone sign the education form when they introduce it" When I sign this form, my understanding is that I am signing that I was present and heard it, not that I am bound to do it.
My question is, am I wrong? When we sign those education forms, are we agreeing to abide ?
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Here is the deal...it is a Joint Commission requirement to have a systematized hand off....however your facility decides to have that hand off is the facilities business....but it must be followed consistently.
Now...these educational "opportunities" on the unit are not meant for you to acknowledge and ignore. If this is the process YOUR unit has "decided upon" then yes...by signing that you were present and are aware this is the process then YES must be followed. We fill out TON of information sheets that are NOT apart of the chart but are required by unit policy for the care of the patient.
You may do as you wish however I would not want to be the nurse who's caught not following the hand off requirement by the Joint Commission when they visit.
My first thought is that unless it is prohibited by hospital policy, or another process is specifically outlined in the hospital policy, then the unit can implement whatever process they see fit. For example, in my hospital, some units used face to face reports, others bedside report, and others used taped report followed by a short face to face update.
I find this "who's to blame" culture to be incredible annoying. Why is it some people spend more time on finding out who is to blame than they would spend if the just did it?! I also agree with others who have stated that the next nurse needs to go to the chart to find out what orders are due on their shift. In the end, I think that if something is missed and you have not filled out the unit form, that could get you in more trouble than if you forgot to put it on the form.
What I am speaking about is not a summary provided by an EMR. It's a separate form that has fields for every body system where you pencil in key info
Ok, but the example you provided was a vanc trough order. I suspect you also put your assessment in a flow sheet on the EHR, correct?
The answer to all unit woes is another form to fill out, of course. I'm curious as to why this is required in your unit. Why the quadruple requirement--orders, verbal report, sheet report, assessment flow sheet?
What I am speaking about is not a summary provided by an EMR. It's a separate form that has fields for every body system where you pencil in key info
I am curious as to why the form makes you uncomfortable? I have notice that shift to shift report goes much more smoothly when there is written for accompanying said report.
Specializes in Leadership, Psych, HomeCare, Amb. Care.
"I personally refuse to fill out this form because I believe it sets you up for trouble. It's not in our hospital policy to fill out such a form."
Hospital policy, is a specific legal process that defines what is to be be done; either on an institutional, or a departmental level. Every unit, in turn, has every right to initiate rules or processes that the manager feels is necessary to make things run more safely or smoothly. You set yourself up for far more trouble, & will be written up for insubordination or non performance, by not filling out the required hand off
Any nurse can write anything in color coded and highlighted lovely-ness on a report sheet. And if this is the standard by which one is being held accountable, there's something wrong with that.
An overworked nurse can forget to do things, and write that they were done on the sheet. Then the next nurse would assume that the sheet is correct, and an order continues to be undone--based on the information provided on the sheet?!
I can also see a "well, I forgot to chart this, but it doesn't matter, as I have written it on the sheet" or "you can check it off as complete, as I wrote it on the sheet...." all sorts of issues.
Sheets are handy brains to remind one of all sorts of information. However, it is not a replacement for a patient's chart. I think it would take one or two of these mis-communication mishaps to occur before management changes its tune.
When receiving a sheet from the off going nurse, I would compare it to the chart, to check for correctness. Any discrepencies would then be written in red, marked as a discrepency--then unfortunetely, you would be then responsible to get new orders for anything that was not done, and then written in red. When the patient is discharged, I would bring said brain to the manager---all the red marks and all, as an example of why this is not a great idea.
It is a general policy of nursing units that the patient's chart should be reviewed by the oncoming nurse. It is a good practice to get into. What Rainbow Bright, RN writes on a paper may prove to be a good supplement, but it should be only a supplement and not treated like a patient chart.
Esme12, ASN, BSN, RN
20,908 Posts
Here is the deal...it is a Joint Commission requirement to have a systematized hand off....however your facility decides to have that hand off is the facilities business....but it must be followed consistently.
Now...these educational "opportunities" on the unit are not meant for you to acknowledge and ignore. If this is the process YOUR unit has "decided upon" then yes...by signing that you were present and are aware this is the process then YES must be followed. We fill out TON of information sheets that are NOT apart of the chart but are required by unit policy for the care of the patient.
You may do as you wish however I would not want to be the nurse who's caught not following the hand off requirement by the Joint Commission when they visit.