MD AWARE

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I was working last week and one of the doc's read my nurses note and was extremely mad and ripped me a new one for writing, pt rates pain 5/10 MD aware, no nursing intervention at this time..... I mean I am a relatively new nurse, alittle over a year, but I was always taught to CYA because if it goes to court the doc is going to try to blame everything on the nurse.... has anyone been yelled at by a doctor for their documentation... He tried telling me that what I document means nothing and if it does go to court he would make up something. Sometimes I can't stand doctors!

Specializes in ER.

If there was a PRN order written I would have given it to the patient. I think this particular Doc just like to fight with me over the littlest things, to try and make me look stupid in front of my co-workers so we go head to head at the doctors station all the time.... but Yes no PRN orders were written, I explained to him the situation and he did NOTHING... I mean OK if you want to be mean to me and not write what I am asking you for but in the end you are hurting to patient not me... but I am no taking the heat when I told you there was a change in the patients condition and you didn't want o write an order because of personal reasons with a nurse.....I am a new young spunky ER nurse and he is an OLD Doctor who has been in the profession for over 30 years, so I think he doesn't know how to handle that big difference quite yet. I like no new orders at this time, I am going to start documenting that instead. Thank you all for your input.... This is what I love about nursing, you learn something new everyday : )

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I never chart "MD AWARE" because 10 years from now I might not know which provider I contact. I always note the name and title of the individual I spoke with and I am very specific as to what I chart I told them. i.e. "John Smith, ACNP notified of decreasing urinary output over the last two hours. decreased arterial systolic BP ranging 60-70's. Tachycardia 120-140's. Mr/Dr so and so notified that patient denies pain at present and is in the bed with eyes closed. Mr Smith, ACNP gave no new orders at this time and stated "Call me back in an hour if nothing has changed" No orders received. Charge Nurse, RN notified of patient status and call to provider."

I have been asked by an attending physician to actually change my documentation before because "it makes my resident look bad" and I quickly informed him that A) He was asking me to falsify a legal document B)He was being unprofessional and C)That he should speak to his resident about listening to me when I called him with a problem.

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Specializes in Cardiac Telemetry, ED.

I never chart "MD aware". This is a subjective statement, and not a description of my actions. Instead, I write "MD notified".

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.

The docs/PAs we work with understand when we have to chart things like that, and it's usually regarding a pt's request for pain meds. Typically these patients have already received repeated doses of something for pain, be it Dilaudid or whatever. I typically chart something along the lines of, "Pt continues to rate pain as x/10 after receiving medication. Pt. requested additional pain meds. MD/DO/PA notified. No additional orders at this time."

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Specializes in Emergency & Trauma/Adult ICU.

Was this a "new" ER patient?

I'm asking, based on this scenario:

Patient from triage to room, clearly doing the kidney stone dance. I get urine specimen, start a line & NSS. Poor patient is diaphoretic, vomiting. MD/NP/PA at desk on phone. If I approach provider, say, "hey, this guy has hematuria, L flank pain x few hours, vomiting, he's really uncomfortable ..." and provider takes chart, nods head and clearly indicates that he/she will see pt. just as soon as off phone and does so ... I will not chart the "MD notified" bit. If, however, I approached provider with relevant info and provider continued phone conversation about vacation travel arrangements, chatted with coworker, etc. for another 30 minutes while pt. paced around treatment room vomiting in sink & garbage can ... you can bet I would chart exactly when I made him/her aware of pt.'s condition and charted "awaiting MD eval" every 5 minutes until he got up off his butt to see the pt.

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First of all, you did nothing wrong.

A couple of thoughts: I have had doc's cover me when I have made mistakes. For example: The order was for ntg x 1. Our docs frequently accidentally order ntg x1, when they want ntg x3, due to our weird ordering system. I gave a second dose, assuming that's what he meant. When we both realized this, he entered an order for the second dose I had already given. While he could (and some would say, should) have given me a hard time about a medication error, no harm was done.

Sometimes a patient will complain of of pain, and a doc will opt not to medicate it. Frequently, this is in the pt's best interest. In an instance like that I would document c.o pain 5/10, dr xxx notified. I would also document pt has no facial grimace, is able to walk and talk without apparent difficulty, and has just finished a eating foot long sub.

I would include that documentation to help cover the doc. While only documenting the pain complaint might be accurate, it wouldn't paint a full picture, and might incorrectly imply that the doc was less than dilligent.

On the other hand, if he is just being a hearltess b*stard, hang him out to dry.

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Specializes in Trauma, Tele, Neuro, Med-Surg.

I chart the same way. It's not about "protecting" anyone in your notes, it's about what happened. Rare is the doc who reads my notes, but if he didn't like it, it's just the facts, and if he was unprofessional about it, then I'd report it as such. I can't cover for his decisions any more than he could cover for me and it woudl be unethical of me to ask him to. It is CYA, but the only way to really "CYA" is to not get caught with your pants down in the first place.

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Specializes in Emergency/Trauma/Critical Care Nursing.

i agree about charting WHO you spoke with because lets say you charted ""MD aware", shortly before shift change and the next RN notices the complaint was never addressed by the MD and has no idea who was supposedly spoken with, OR the MD wasn't really paying attention and acts like its the first time hes being informed of problem, may reflect back on you that you didn't actually address the issue but charted that you had as vaguely as possible.

I also agree w/above posters that i NEVER change my charting "because the MD doesn't like it". charting is supposed to be a recording of exactly what you assessed/were told/saw/smelled etc. and is meant to be totally objective. Typically its not an issue in my ER of MDs reading the nursing notes on the chart, they tend to read the initial charting under the triage tab and expect us to notify them if there is something abnormal or causing concern that would be documented in nursing notes. Also regarding the MD aware issue, it is our hospital policy and as far as i knew, a jahco requirement that pain must be reassessed often (don't remember how frequently), that if pt DOES c/o pain, an intervention must be done, whether its strictly a nursing intervention or notifying the MD, however u must also go further to say whether u have new orders after telling MD or if they stated they will not be ordering anything at this time. if you just write that you informed MD but he gets sidetracked or just doesn't want to order anything and doesn't feel it necessary to explain why, then you really haven't done any intervention at all, you just passed a message along from pt to MD lol. My example for a situation similar to that would be "pt c/o sharp abdominal pain to LUQ x 1day, currently rated 9/10 on numeric scale, unrelieved by motrin taken at home and is worse with movement and/or palpation to area. pt assisted to position of most comfort and given pillows/blankets. Dr. X made aware of pts pain level, stated to writer that they will be in to re-evaluate pt shortly and will notify writer of any orders at that time, no new orders as of yet dr. x currently at bedside, will continue to monitor" -that one is kind of on the long side because i'm basing it on a pt that presents primarily for pain. and if after the doc sees them, they don't order anything nor do they approach you to explain why and what their plan for intervention WILL be w/in 30min or so i approach them to find out, if they aren't willing to order meds because they THINK the pt is seeking or something stupid like that i will tell them that THEY will be explaining to the pt why they aren't ordering meds, and chart reflecting that.

just remember, one of my favorite aspects of ER is the level of autonomy that RNs have in that dept, plus its generally a better RN/MD working relationship because they work more closely together, i know you said you were still newer, but trust me you'll become more confident and will start to realize that the MDs AREN'T your boss, and they aren't gods either, they WILL make mistakes and don't be afraid to call them out on it if it means you're advocating for your pt. Good luck, hope my rambling helped at all lol

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