Liability question

I believe that Hep B vacs are given in a series of 3.

Shot #1 then 30 days later shot #2 then 6 months later shot #3. Not sure about the liability situation. But I find it hard to believe that documentation was "forgotten" three times. There should be some financial record to go along with the medical record to help research this. I believe it is usually better if you are unsure or don't know the answer to their question, to tell the patient that you will call them back when you do have the correct answer. We have all been there and done that with an accidental "slip of the tongue".

Okay you were being a human being and being truthful...however, you have to deal with people that are not going to understand because RN's and MD's aren't supose to make human mistakes! GRRRRRRR!

But...I would simply say that it is not recorded in the chart and what can I do to help. That way I am out of the blame game and trying to be helpful.

But hey...you told it as you saw it...so she is being a turkey. Oh well...

I agree with TriageRN, I'd probably just say that it's not in the chart and leave it at that. I usually refuse to speculate with a patient why someone else did or did not do something. I also try to redirect back to the issue at hand: "I don't know what happened, but we have no record of the immunization. I would suggest that we...." and go on from there.

But did you break some huge rule and do something wrong? No.

If this doc had been in practice for many many years, he may not consider documentation as important as we do now. I've seen very old clinic charts, from the 1960's, with an entry like:

sore throat, red, penicillin.

Yes, that was it!

And, back then, nobody cared.

Regardless of how it came to not be on the chart, it is what it is and go on from there.

And papers do occasionally get lost or misfiled.

Thanks Santhony! Actually I have a unit secretary staying at my house (my best friend) that agreed too. Sometimes she slips and her human side comes out and oops! But generally just sticking to facts at hand is the best measure in this day and age!

Assumptions are not good anymore...in no cases anymore because of HIPAA, Liability, and PC! So if it isn't factual and can be proven...dont' even go there... because no matter how innocent a comment was or truthful either...you will get it..and sadly it is turning guilty until proven innocent! GRRRRRRR!

Remember what they say about assume...it makes an A** out of you and me! LOL!!!!!!!

I am sure there have been times when I've responded to something with "say what???" or when I've been unable to get my facial expression under control quickly enough, but most times the less said the better.

I've also had people swear up and down we did something at one place that we didn't and people tell me I did or said something when I wasn't even employed at the facility at the time.

Exactly right about assuming!

Oh lordie..I have done the same with my facial expression! LOL, I am human! But I try really hard to catch that quick and give that old Nurse expression! LOL!!!!!!!

I am a human nurse by far...I am easy going and laid back but always serious on the inside and thankfully very socially appropriate (which is a hard thing to do in all situations...I don't get it all right with some patients!). And well...some patients can't be pleased, and I then start looking and asking questions about why they are so fearful so I can help!

Last night I had a wonderful sweet patient...but my red flags were up on something I couldn't quite fathom. She was in for sudden onset of hyperglycemia...500's. Found out through converstation and active listening that her mother on vacation to hawaii got sick..went into the hospial and died of hyperglycemia! Okay stress level to extreem? I sat back and told her the skinny..including the realistic probelms and what not...basically I gave her the simplified but real situation! she appreciated it. I didn't say her MD, who admitted her without knowing what was happening, was to blame...but that the MD was so caring as to get her in fast and we would explain later..that helped her so much even though she really wanted to know why she was admitted and was fearful! I tried like mad to get the MD to come with no avail...but that still didn't hinder me in my talking to the patient...I simply said...she has reason for not being here right now..and I can't assume why...but I am here, I have MD's I can talk to...I will advocate and keep you safe! And I am your help, and I will do whatever necessary to make you safe and informed!

Found out the MD wanted the day off and turned off her phone, and her answering service was out...nice huh? The MD will be written up (I did), but regardless it is my job to help the pt...not assume anything...but help with the here and now! And I did!!!!!!!

Actually #1 depending on the age of the girl isnt the mother somewhat responsible to keep track of her immunizations if nothing else for school records? And #2 if she had the hepB immunizations for her school (which is required in a lot states for elementary/high school age children) wouldnt the school have a record of the shot dates? That information is held in their permanent school records too. I know i can go online and see all my childrens information including grades, missed assignments, attendance and immunizations they have had and dates through our schools website.

Meow..so great to see you hon! I thought the same thing actually..thank you for bringing it up!