Legitimate gripe or much ado about nothing?

[maxthecat]

When I was checking over a visit note from one of the doctors I came across the following: "Pt's mother states nurse never told her about pt's new medication." No other comment on this.

Now if someone were to check other notes they would find that the nurse (me) did indeed inform the mother about this. But if the doctor's note is read on its own, the conclusion I draw is that the nurse failed to do her job properly.

I know that I have sometimes charted a patient complaint about a physician, but I always provided a comment that shows evidence of "the other side of the argument." I've never just reported a negative comment and not investigated further. I would have been a lot happier seeing something like "Pt's mother states nurse never told her about pt's new medication. Will check with nurse and review documention of pt/parent teaching."

Some would say the doctor is just reporting a comment. No evidence that the doctor believes this is true or not true. I guess I just feel that someone reading the note is going to believe the doctor believes the parent because there is no indication of any plan to investigate. And I feel a little bit thrown under the bus. Am I being overly sensitive or is this sloppy charting?

[JBudd, MSN]

I wouldn't obsess over it, but the doc obviously wasn't thinking about the larger implications of the comment. They don't have to put in the CYA "plan" (will investigate etc.). If you see the doc, you might mention "hey, I did inform her, and charted it..." and see what the response is.

Unless this doc makes a habit of sniping at nurses in the notes, it probably isn't worth pursuing very hard.

[amoLucia]

Just as you were able to backtrack and cross-check your notes, so can any other interested parties. Your documentation is there.

This is an example of how good documentation saves the day! Good for you.

[nurseprnRN, BSN, RN]

If this came to a lawsuit for some reason, the first thing the legal nurse reviewing the file that only included MD notes would say would be, "Where are the nursing notes?" This is because about 75% of the time the attorneys only think to request medical notes and procedure notes, labs, diagnostics, etc., and don't think the nursing notes are important. But they are, and we tell them why, and then they never make that mistake again.

But you might want to clue in your doc that his note was incomplete in this regard and it would be helpful if he documents the collegial aspect of your practice by documenting that he checked your notes on patient/parent teaching and found them in order.

[generalRN2008]

Do you use care notes, micromedix, or other written education for patients? Always helps to put a signed copy in the paper chart. Also, the doctor is supposed to explain new orders to patients before writing them unless it was a telephone order, it would be the nurse to explain the first time

[psu_213, BSN, RN]

I think it's much ado about nothing, and, IMHO, he did not throw you under the bus...he just "quoted" what the family member said--he did not add judgement to it. Sure, it may look bad if you just view his note in a vacuum, but the doctor's not is not the only documentation that exists.

In my mind it is definitely not sloppy on the part of the doc--but, it it bothers you that much, I would mention it to the doc that you did tell the about it, etc., as others have mentioned.

[HouTx, BSN, MSN, EdD]

"Patient's physician makes entries without reviewing nurses' notes"

[Ruby Vee, BSN]

I don't think he deliberately threw you under the bus -- it's just sloppy charting. The next time you see him, mention that you did do the teaching and let him know where he can find that documentation. If he continues to make entries like this, though, you might want to talk to your manager and see if she can have a chat with him.