How to CYA

[cinja]

This is a silly question but how do you CYA in nursing? I am looking for various examples and stories. I would like to compile a handout for my fellow students before graduation. Like do you keep a journal or record every conversation you have or what. Issues instructor feels this is not important enough to waste her time with and I disagree because I have been a cop for too long in this world we live in to think otherwise. This I think is just another tool in the new nurses small little tool box.

[Ruby Vee, BSN]

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

[Daytonite, BSN, RN]

i think that when it comes to conversations you just have to develop a kind of red flag about things. if you are discussing something that seems like it might be potentially important some day then i would summarize the important points of it and chart that during the phone conversation with ___ these points were discussed. i had a patient once who, during shift report let her own side rail down, got up to the bathroom, fell and broke both hips. red flag. how often does that happen? i figured that this was one that would end up on a lawyer's desk somewhere. what i remembered doing, and what i often do now, is start listing things that happened chronologically along with times if i know them. then i chart from that list. i keep things factual and try to include as much as i can. never got so much as one call over that incident. also, i draw pictures. for most falls, i usually draw a picture of the position i found the patient in. i'm not an artist, and my people are stick figures. however, when someone has had a pretty twisted up arm or leg i have been able to show that a lot easier with a picture. there is no rule that says you can't draw a picture on your nurses notes. i've also drawn pictures of wounds along with putting their measurements down when no form was available for this.

when i became a nursing supervisor i was amazed to find out just how much documentation was done by supervision and management that staff nurses didn't know about. we had a special form called an administrative report that was nothing but a piece of paper with lines on it. all we did was a write up of incidents as factually as they happened just as we would for a patient's chart except that these went to the nursing office into files. i made a xerox copy of every administrative report (and every employee i wrote up in later jobs) and i have a file of them at home.

when i started doing disciplinary write-ups on subordinates i also started saving copies. at first i needed the copies to help write other reports. it was hard to be objective and factual on some of these write ups at first which is why i started saving them in the first place. they were also learning tools at first. you really don't get much practical experience with employee problems in nursing school. i felt like i was kind of left hanging on my own in learning to deal with that kind of stuff.

for many years when i was a staff nurse i kept my daily report sheets. i had a box at home just for them. i was afraid to throw them away for fear that there may have been something important on them that i might have forgotten to chart that might come back at me later. every report sheet was clearly dated. whenever i called a doctor i wrote my notes of my conversation with the doc on the back of those sheets. i didn't care if a facility said saving them was a breech of confidentiality. i felt that protecting my license was more important and i wasn't going to be showing these to anyone anyway.

i developed my own very unique way of signing off doctor's orders. i make a very elaborate arrow at the top and bottom of a bracket around orders i am signing off and place it so the top arrow points to the first order in a list and the bottom arrow points to the last order in a list so that doctors cannot come back and add another order without my knowing they did so. i've known of doctors who have written orders to cover their own butts in the same group of orders a nurse already signed off that makes it look like the nurse missed that order. guess who gets in trouble? not the doctor.

if i call labwork to a doctor i make a notation somewhere on the lab print out that i have called the doctor at the date, time and which value he was told about. i chart the exact same information in the narrative notes as well since some facilities update labwork and run new print offs every day and throw the previous days print outs (with my notation on them) away.

every time i call a doctor i document what i told the doc and what orders, if any, were given. if it takes 3 calls to get the doctor i will note that in my charting along with the time of the first call and the time that i eventually got in touch with the doc. i also chart when i call a supervisor or another nurse to collaborate and make a decision so it is in writing.

i take charting very seriously and over the years have learned that many departments depend on what is in the chart. if i see pt in a room working with one of my patients, i will chart that i saw them there and what i saw the patient doing with them. i will ask a patient if his doctor visited him today if i didn't happen to see him. if the patient says he did i will chart that the patient told me the doctor visited him. don't laugh, but one of the biggest problems i see happening is not keeping track of patient's bms, especially when they've been in the hospital awhile. a patient suddenly starts complaining of abdominal pain and announces he hasn't had a bm in a week. people start looking at the chart and son-of-a-gun there's no bm charted for week. how did something so simple get missed? nothing is worse than having to spend a good part of your shift having to give enemas or cleaning up the result of laxatives given to a patient who is fos.

and, the very last thing i do is make a very quick round to make sure my patients are alive and breathing. in fact, i check them as often as i can throughout my shift. it would be pretty embarrassing to tell someone that a patient is doing ok only to have them come back at you in a panic shouting that he is lying stone cold dead in the bed. oops.

[rnElaine]

Excellent tips from daytonite!! I would only add, as another poster said, to keep a copy of all incident reports you write, as well as memo's, brief journal entries of concerns you have for each day in your own journal/notebook. Keep a copy of your annual employee review. Get personal malpractice insurance!!!

[introspectiveRN]

Thank you all for posting this...so much good, sound advice here. Especially thank you daytonite . I have printed these off and plan to share them with some of the other students that graduate in six weeks too.

thank you!!!

[daisybaby, LPN]

Wow, good suggestions. I especially like the tip about signing off orders so no one else can squeeze others in- I'll be using that one, starting tomorrow.

[control]

i think that when it comes to conversations you just have to develop a kind of red flag about things. if you are discussing something that seems like it might be potentially important some day then i would summarize the important points of it and chart that during the phone conversation with ___ these points were discussed. i had a patient once who, during shift report let her own side rail down, got up to the bathroom, fell and broke both hips. red flag. how often does that happen? i figured that this was one that would end up on a lawyer's desk somewhere. what i remembered doing, and what i often do now, is start listing things that happened chronologically along with times if i know them. then i chart from that list. i keep things factual and try to include as much as i can. never got so much as one call over that incident. also, i draw pictures. for most falls, i usually draw a picture of the position i found the patient in. i'm not an artist, and my people are stick figures. however, when someone has had a pretty twisted up arm or leg i have been able to show that a lot easier with a picture. there is no rule that says you can't draw a picture on your nurses notes. i've also drawn pictures of wounds along with putting their measurements down when no form was available for this.

when i became a nursing supervisor i was amazed to find out just how much documentation was done by supervision and management that staff nurses didn't know about. we had a special form called an administrative report that was nothing but a piece of paper with lines on it. all we did was a write up of incidents as factually as they happened just as we would for a patient's chart except that these went to the nursing office into files. i made a xerox copy of every administrative report (and every employee i wrote up in later jobs) and i have a file of them at home.

when i started doing disciplinary write-ups on subordinates i also started saving copies. at first i needed the copies to help write other reports. it was hard to be objective and factual on some of these write ups at first which is why i started saving them in the first place. they were also learning tools at first. you really don't get much practical experience with employee problems in nursing school. i felt like i was kind of left hanging on my own in learning to deal with that kind of stuff.

for many years when i was a staff nurse i kept my daily report sheets. i had a box at home just for them. i was afraid to throw them away for fear that there may have been something important on them that i might have forgotten to chart that might come back at me later. every report sheet was clearly dated. whenever i called a doctor i wrote my notes of my conversation with the doc on the back of those sheets. i didn't care if a facility said saving them was a breech of confidentiality. i felt that protecting my license was more important and i wasn't going to be showing these to anyone anyway.

i developed my own very unique way of signing off doctor's orders. i make a very elaborate arrow at the top and bottom of a bracket around orders i am signing off and place it so the top arrow points to the first order in a list and the bottom arrow points to the last order in a list so that doctors cannot come back and add another order without my knowing they did so. i've known of doctors who have written orders to cover their own butts in the same group of orders a nurse already signed off that makes it look like the nurse missed that order. guess who gets in trouble? not the doctor.

if i call labwork to a doctor i make a notation somewhere on the lab print out that i have called the doctor at the date, time and which value he was told about. i chart the exact same information in the narrative notes as well since some facilities update labwork and run new print offs every day and throw the previous days print outs (with my notation on them) away.

every time i call a doctor i document what i told the doc and what orders, if any, were given. if it takes 3 calls to get the doctor i will note that in my charting along with the time of the first call and the time that i eventually got in touch with the doc. i also chart when i call a supervisor or another nurse to collaborate and make a decision so it is in writing.

i take charting very seriously and over the years have learned that many departments depend on what is in the chart. if i see pt in a room working with one of my patients, i will chart that i saw them there and what i saw the patient doing with them. i will ask a patient if his doctor visited him today if i didn't happen to see him. if the patient says he did i will chart that the patient told me the doctor visited him. don't laugh, but one of the biggest problems i see happening is not keeping track of patient's bms, especially when they've been in the hospital awhile. a patient suddenly starts complaining of abdominal pain and announces he hasn't had a bm in a week. people start looking at the chart and son-of-a-gun there's no bm charted for week. how did something so simple get missed? nothing is worse than having to spend a good part of your shift having to give enemas or cleaning up the result of laxatives given to a patient who is fos.

and, the very last thing i do is make a very quick round to make sure my patients are alive and breathing. in fact, i check them as often as i can throughout my shift. it would be pretty embarrassing to tell someone that a patient is doing ok only to have them come back at you in a panic shouting that he is lying stone cold dead in the bed. oops.

all of these are excellent, but the last one has cma most of all! by checking on your patients often, you're less likely to get nasty surprises, that's for sure.