you can document anywhere! the er nurses notes with addendums are good places to start. as long as you are not sounding accusitory (sorry, i really can't spell) it is ok, ie; "pt complaining of pain. attending and er md's made aware and no further interventions ordered at this time." interperatation, this is the 5th such documentation and the er md doesn't want to get ivolved and the attending doesnt' either.
you just have to learn to document the facts only with out emotions (and i know how hard that can be!:chuckle! cause some people warrent lots of emotion.) have you ever written an incident report? try charting like you are writing one of those, just facts and what the involved parties say.
i know is sounds cynical but unfortunatly, we live in a law suit happy world! good luck, magik girl:cool:
Let me just say that the last nurse who started filling out incident reports and sending them to risk managment...no longer works for us. Interesting don't you think.
We just started a new tracking system really more designed to for staffing in general...I think i will make copies and start a log. I am just not sure if that is protecting myself or opening myself up.
I just do not know the answer. I need a legal nurse consultant. Anyone out there?
Let me just say that the last nurse who started filling out incident reports and sending them to risk managment...no longer works for us. Interesting don't you think.
We just started a new tracking system really more designed to for staffing in general...I think i will make copies and start a log. I am just not sure if that is protecting myself or opening myself up.
I just do not know the answer. I need a legal nurse consultant. Anyone out there?
as i said in one of my previous posts, i have reviewed charts for an attorney. i am not saying that this makes me an expert but i have seen the consequences of poor documentation.
i also did not say to file incident reports. what i said was to document in your charts the way that you would document on an incident report - without emotion and non accusing, just the facts.
It seems to me that no one is asking why are there so many ICU holds in the first place? Why are all these (usu.) gomers clogging up the system? Were they always there? What disease processes are most likely to contribute to these patients winding up like this? As always, it seems that prevention would solve a lot of problems. But our society doesn't value that. And really, did you enjoy your community health experiences? Resources are so scant for that sort of thing. But I'd pay more taxes for programs to teach fat smokey diabetics how to surf, sure.
That aside, there are only 12 (13 really) hours in my shift. How am I supposed to document every little thing (by hand mind you because nursing doesn't believe in computers much, yet) and still do the actual care? So many times, it seems that I barely can actually get the IV's and meds into the patients, much less document it. Why does the FEDEX guy have a better computer system than me? Why am I triple documenting some things and not others? I don't know. And neither does anyone else, I work with.
I'm a military RN and one of my (additional) assignments is to audit our ER nursing documentation. I'm proud to report there's been a 100% improvement in nursing documentation since I took it over.....but that's coming from a 30% baseline to a 60% baseline. That means we're only documenting all the stuff we absolutely said we have to 60% of the time. A lawsuit waiting to happen. But what can you do? My saving grace is that I can't be sued by a substantial portion of my patient population.
We say documentation is key...but there's no innovation to enable us to do so efficiently. But thanks for reading my tangent.
It seems to me that no one is asking why are there so many ICU holds in the first place? Why are all these (usu.) gomers clogging up the system? Were they always there? What disease processes are most likely to contribute to these patients winding up like this? As always, it seems that prevention would solve a lot of problems. But our society doesn't value that. And really, did you enjoy your community health experiences? Resources are so scant for that sort of thing. But I'd pay more taxes for programs to teach fat smokey diabetics how to surf, sure.
That aside, there are only 12 (13 really) hours in my shift. How am I supposed to document every little thing (by hand mind you because nursing doesn't believe in computers much, yet) and still do the actual care? So many times, it seems that I barely can actually get the IV's and meds into the patients, much less document it. Why does the FEDEX guy have a better computer system than me? Why am I triple documenting some things and not others? I don't know. And neither does anyone else, I work with.
I'm a military RN and one of my (additional) assignments is to audit our ER nursing documentation. I'm proud to report there's been a 100% improvement in nursing documentation since I took it over.....but that's coming from a 30% baseline to a 60% baseline. That means we're only documenting all the stuff we absolutely said we have to 60% of the time. A lawsuit waiting to happen. But what can you do? My saving grace is that I can't be sued by a substantial portion of my patient population.
We say documentation is key...but there's no innovation to enable us to do so efficiently. But thanks for reading my tangent.
why are there so many ICU holds??? In our case its because of over utilization by the admitting docs. Some absolutely refuse to admit patients to med surg even though they are med surg patients. I can only assume that is because our ICU/CCU nurses are allowed to have routine orders and the floor nurses dont. Hence, the docs arent called as much at home
I can guarantee you, the 95yr old DNR stroke victim could be just as well cared for on the floor... AND our UR dept are non-confrontational...
so what if you have icu patients holding you chart your assessment and at the end chart "awaiting bed on blah blah" ?
Recently a patient was transfered to me in ccu and the ER nurse had documented "waiting on ccu bed" 3 times. This was discussed at some length between the NM and others and it was decided that this was not appropriate for legal reasons.
Recently a patient was transfered to me in ccu and the ER nurse had documented "waiting on ccu bed" 3 times. This was discussed at some length between the NM and others and it was decided that this was not appropriate for legal reasons.
If this documentation is not appropriate, then, how do we document the reason for delay in transporting patients to the critical care areas?? There are times in our hospital when it takes 3 hours(from the time the room is assigned) for a patient to finally get the go ahead to be transported to the units.
I dont want this to come back on me, I have done my part, I have tried to call report numerous times without success and the bed has been assigned for 3 hours. What is the solution to this problem?? All of our ER nurses document when they try to call report/ transport patient (but the units wont take the patient), but it is in a non-accusatory manner. I usually put, "CCU unable to take report at this time."
Now, I dont document that every 20 minutes, mind you. Once an hour is enough.
I have a friend that says the same thing. Plus, one of the nurses I used to work with on Tele has a friend who is a legal nurse consultant...documentation is the key. But here is the dilemna...
Document where?
We are not union...so no grievance forms.
It doesn't seem right in the patient charts.
Do we need to create yet another form?!!?
It is so paranoid but also so needed, I think. Just to CYA...
:eek:
If you have hospital email this is a good way to document that can not be placed in the trash or disappear. remember to make a copy and take it home for safe keeping. The quality aassurance/ incident report is another avenue to think about. The are required to investigate by the Joint Commision. Make sure you go through the policy book and follow the notification process to the letter. Look at it this way. If you report and lose your job you can always get another one. If you do not report unsafe situations the nursing board can take your license and you can not work at all. There is no easy answer. PROTECT yourself because believe me they hospital will not run to your rescue. Notify the appropriate chain of command and document dates, times and names of who you spoke to and the also the conversation. I kept a journal. Saved my butt a time or two. I was a manager and this is why I left. I could not ask my nurses to work in an unsafe environment that I myself was not willing to work in. I loved ER but the legal risks are too great and quite frankly my children need food more than I need to love my job. Good luck!!!!!
If this documentation is not appropriate, then, how do we document the reason for delay in transporting patients to the critical care areas?? There are times in our hospital when it takes 3 hours(from the time the room is assigned) for a patient to finally get the go ahead to be transported to the units.
I dont want this to come back on me, I have done my part, I have tried to call report numerous times without success and the bed has been assigned for 3 hours. What is the solution to this problem?? All of our ER nurses document when they try to call report/ transport patient (but the units wont take the patient), but it is in a non-accusatory manner. I usually put, "CCU unable to take report at this time."
Now, I dont document that every 20 minutes, mind you. Once an hour is enough.
I agree. We document the same way here.
The old adage...not documented not done.
I think that the lawyers and floor managers don't want it documented because it DOES open up some legal issues. But that is the point.
If there is a bad outcome related to delay in transfer...let the truth be told.
:eek:
RNin92
444 Posts
Let me just say that the last nurse who started filling out incident reports and sending them to risk managment...no longer works for us. Interesting don't you think.
We just started a new tracking system really more designed to for staffing in general...I think i will make copies and start a log. I am just not sure if that is protecting myself or opening myself up.
I just do not know the answer. I need a legal nurse consultant. Anyone out there?