Inappropriate documentation?

[Emily Simmons]

So back story, working in LTC and had someone that’s a daily fall, fall on my shift and become hurt. I completed our fall protocol, and notified all correct people. After following up with hospital to check on admitting/sending back patient I put in following note:

”resident to be admitted to BLANK hospital with current diagnosis of BLANK”

I was reprimanded for doing so. However, we typically are expected to follow up on if our patient is to be sent back or admitted, along with placing a note. Now I’m being told I improperly acted because I should’ve kept that info privately to our DON.

Opinions?

[BSN-to-MSN, ADN, BSN, RN]

It's not wrong to follow up on the patient, but I think "to be admitted with a diagnosis" is not a fact. The medical diagnosis for admission is not clear until patient is seen by admitting MD. The documentation should say the narrative of the follow up phone call as previous posters pointed out.

Good learning situation, though.

[JKL33]

On 7/14/2020 at 7:00 AM, Emily Simmons said:

”resident to be admitted to BLANK hospital with current diagnosis of BLANK”

Nothing wrong about this type of note, although I would write in a way as to be clear that it is reported information: "Phone call to [facility] to check on resident. Per ED RN, resident to be admitted for dx of [primary admission dx]."

On 7/14/2020 at 7:00 AM, Emily Simmons said:

Now I’m being told I improperly acted because I should’ve kept that info privately to our DON.

Sounds like they need to make up their mind about their documentation policies. A good, neutral-pleasant response to this type of thing (and many other interesting confrontations) is, "Where can I review that policy so I know what to do going forward?"