Jump to content

How do you document when drug withheld?

Posted

Hi! I know this may be out of the topic, but I just would like to ask Australian nurses esp those in QLD, how do you document on the medication chart when a drug is withheld because of abnormalities in the vital signs? thanks!

ghillbert, MSN, NP

Specializes in CTICU. Has 20 years experience.

Depends on the institution drug chart - it should have a legend/key with a list of things to write for "refused" (eg. "R"), "withheld" ("W"), "not given" etc.

Silverdragon102, BSN

Specializes in Medical and general practice now LTC. Has 32 years experience.

Moved to a thread on it's own as off topic to the one it was in

thank you for the reply!! =)

AussieTina

Specializes in Medical, Paeds, Ob gyn, NICU. Has 2 years experience.

In QLD health you write a W on the drug chart and then document the variance in the care plan as to why the drug was withheld, you are also meant to notify the doctor that the drug was withheld. Although I know on my ward the docs are not normally notifed, unless it was a really unusual vital sign that you obtained.

thank you for the reply! I would also like to ask what does PG signify when a drug says lanoxin PG? is this the drug for geriatrics? and what is a red label in an IVT? thank you so much for any information...

pcolaqtfighter77

Specializes in medical/surgical, acute care, psych..

In florida, United states, we initial, if a paper MAR, and circle the initial. Its good practice to also make a nurses not to justify your actions....if it was a drug such as coumadin/warfarin, i would definately notify MS if a pre arranged parameter wasn't written....sorry, didnt realize u were asking for Austrailian nurses...lol us damn Americans....:)

carolmaccas66, BSN, RN

Specializes in Med/Surg, DSU, Ortho, Onc, Psych.

From what I can see on the web, PG seems to stand for paedatric and geriatric.

I didn't know this either!

talaxandra

Specializes in Medical.

Digoxin comes in two strengths - the smaller dosage (PG) is used for children and older patients, hence the pediatric/geriatric.

In Victoria we write W/H for withheld meds, and include a comment in the notes.

dvsbec

Specializes in ED, L+D,. Has 11 years experience.

Ziggyldy - the red labels on IV fluids usually indicate that another medication has been added to the bag. it will document the medication added, the dose, the patient it is for, and the time and date it was added, plus the signatures of 2 nurses who added/checked the medication.

and as others have replied, here in queensland, if a medication is withheld, it is documented on the medication chart W with a circle around it. then documented in the patients chart as to why it was withheld, plus doctor informed if required.

hope this helps,

Bec

rozymisty

Specializes in ENT, Maxofacial, plastics, opthamology.

hm do you guys find that people dont do the 2 nurse check properly? Like 2 pple are there when its mixed and added, and then you both go to the bedside and physically check the name band?

we had an inservice a few months ago, and they did it for like a few days and everyone got annoyed with it. the previous hospital i worked at, we'd double check heparin, but on my new ward, they dont bother..but are starting too. U'd think especially with heparin you would double check it!!!

Hoosiernurse, ADN, RN

Specializes in telemetry, cardiopulmonary stepdown, LTC. Hospice. Has 12 years experience.

Doesn't anybody in Australia have computer charting?? Just curious...

HoosierNurse

talaxandra

Specializes in Medical.

rozymisty - single checking is considered an earned privilege where I work; anyone caught not properly double checking loses it for a minimum of three months or, is they're still doule checkers, a further three months is added to their time before they're allowed to begin the accreditation process.

Hoosiernurse - not that I've heard, but I could easily be wrong; a couple of Victorian hospitals have begun scanning histories electronically on discharge.