Is my adon crazy? Or is it me? Rant

[calliesue]

Ok so I go into work this weekend at my LTC weekend job and there is a typed note to nurses telling us from now on we should shred faxes we receive back from md after we have written T.O. and charted it in the nurses notes, so the charts wont be so thick.

I will always write the T.O. and chart it, but I don't think I will be shredding anything that comes across the fax with an MD signature, order, or note on it, cause I think at the point at which the Md writes on a fax it is part of the medical record.

One other really crazy thing , ADON told nurses on our hall that we did not have to do an incident report on one of our "frequent fallers", because it is care planned on the chart.

I wonder if State Surveyors or Lawyers would agree with this, or will they hold us nurses to the minimal standard of the policy and procedure; which states "all falls will be followed with an accident and incident report and investigated". Not to mention neuro checks if fall unwitnessed. (yes I looked up the policy and procedure)

ADON said when asked about this, " Well I just meant if she falls because of her Tias".

I guess now, not only can I destroy part of the medical record, and circumvent policy and procedure , I can dx too.

Awesome!

[txspadequeenRN, BSN, RN]

i never shred anything that has a order on it. i mean sure we can take verbal orders but having a signature from the go is a good protection for us. at other jobs i have taken the fax just like a regular order and placed it in the chart. my job now has a fax book where we keep all of them. i fill out a ia for every fall regardless of why i or the don/adon thinks they have fallen... sounds like your boss is crazy and lazy...oh my i made a rhyme...lolol

are you familiar with the initials cya

[scarlet]

I Agree. I am an ADON & I would never tell anyone to distroy anything from a MD. IR on EVERY incident espically falls, Our Charge Nurses complete the IR, complete an unusual occurance form, notify RP, MD, Inservice staff. I investigate, track & trend all falls, complete a post fall assessment, update the care plan as well as the fall assessment, the DON reviews my post fall assessment to r/o neglect / abuse it is then passed on to the Administrator who will r/o abuse / neglect (as he is our abuse coordinator). We too keep a "fax binder" of all faxes received. If the fax has anything to do with the fall it will be attached to the IR with all others listed above to complete the investigation.

[caliotter3]

Your ADON for some reason has given out wrong headed instructions. You never destroy a piece of paper with the doctor's order and his signature. What in the world is she thinking? That is a written part of the medical record. What do you produce if there is a question (such as at a legal proceeding) and there is no signed written order to back up the TO that is written by the nurse? And no report on a fall? She is asking for trouble and will get it sooner or later. You need to speak to the DON and point out your misgivings. Meanwhile, I would continue to place the faxed copies of orders where they can be accessed. Also, write a memorandum detailing her instructions, in case you have to answer for this in the future.