How to CYA

Chart documentation, that's what it's there for. If it's not documented, it's not been done, legally speaking.

Not to sound ungrateful but I think that good charting is understood. I am looking for the more creative ways to CYA. For instance, when dealing with management do you record the conversation? I hope this helps the thought process.

Basically, I think that in CYA management wise, I would print off any office memos, e-mails etc. that are exchanged and keep them in case the issue would ever come up in court. Keeping a journal with notes as to what was discussed in meetings could come in handy someday, but not necessarily the most important thing in my mind - like you said, documentation is definetly the best way to CYA, and that should be understood. Beyond that, I'm not sure what kind of situations you're asking about, so I don't know exactly how I would choose to cover my a$$ so to speak.

I'm with janelle. How would you need to CYA other than documentation?

If I'm having issues with management, document those. I would never record a conversation with a manager. If it got to a place where I felt I needed to record conversations, I need to find a new job, or have a witness in the room.

If you document well in your charting, and document instances of harrassment, there's not much else to do. It honestly seems pretty out there to think about recording conversations and things.

I don't know if it is different state to state, but here in SC you can keep a "personal journal" that includes names (patient family members who have complaints etc.). what you can't do is make copies of any medical records (including your own nurses notes) d/t hipa violations. Hope this helps.

Thanks Wendy Thats the ideas I was looking for. Any others?

I'm with janelle. How would you need to CYA other than documentation?

The first thing that comes to my mind is to never assume that a pump is set correctly and/or the right IV solution is hanging just because the previous nurse documented it that way. I always start my shifts by verifying that all drips are correct (right fluid, IV pump/PCA/IV drip rate is correct, etc.) so that I can't be held liable for giving the wrong med/fluid. And I'm sure this goes without saying, but I would never give a medication that I didn't draw up myself and verify against the MAR. Also, don't witness the waste of a narcotic unless you actually witness the waste (i.e. don't just sign off on the Pyxis and then walk away while the other nurse draws it up).

But that all falls under documentation to me, at least on my unit. We are required to document what's infusing and how fast every hour. The things with family interaction, we also document in the chart.

She seems like she's asking about CYA in non-nursing ways.

Like do you keep a journal or record every conversation you have or what.

That's what I'm talking about. I'm wondering what specifically the OP thinks might happen that you should be recording every conversation you have?

Keep your skills up.

Network.

Stay abreast of what is going on in the field of nursing.

Get malpractice insurance.

Join your state/provincial nurses association.

If it is something that concerns the patient's care I will document it in the nurses note, if it is something that concerns myself and say the nursing supervisor I will write up an incident report. For example the other day someone put a foley catheter and some dirty wipes in the big sharps container that we put our needle boxes in and large sharp objects-that day there was large pieces of glass . The nursing supervisor came and told me to get gloves on and since I was in charge to stick me hand in the sharps container to get the foley and dirty wipes out.(This supervisor is notorious for writing people up for insubordination) I told her to stick her own hand in I wasn't going to do it and how dare her to put me at risk that way. Later I found out she did the same to the nurse in ER and they put their hand in the container. I wrote her up and notified my unit manager.

Be nice (or at least cordial) to everyone. You never know what will happen or who you will be working with (or for) in the future (not saying "be a brownnoser", but don't be a ***** either!).

make sure you know what your hospital policy is and adhere to that as written, not to "common practice." if you disagree with your policy (and science changes, so you may), work to have it changed.

keeping a journal is a great idea, but be aware that it attorneys know it exists, they can subpoena the whole thing -- so keep anything personal out of it.

ruby