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Discussion

Inappropriate documentation?

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?

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    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?"

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