Medical Charting in Family Practice.

Sewbusy~RN · Dec 14, 2011

I don't think there's anything wrong with what you charted. The important thing is to be objective and honest and just state what happened, when it happened and how it happened. It is what will be used in court so it better be as factual and accurate as possible if you are the one under fire, in my opinion. I know you can never chart it when you do an incident report, but I've never heard that you can't put peoples names in there if they made a decision that directly affects the patient.

RFRN · Dec 14, 2011

You did the right thing. I'm sure that nurse just wants to avoid anything coming back on her so she didn't want her name associated with not having the patient seen that day. I agree with you, the pt probably should have been seen if the MD had time in their schedule. As an RN in a clinic setting, if I am told anything by another nurse/MA/doc, I chart it so it doesn't come back on me. Who knows if these sores end up infected or something happens and you don't chart that you brought it to someone's attention, it could look like the patient told you and showed you these and you did nothing! Don't listen to them, cover yourself!

nurseprnRN, BSN, RN · Dec 14, 2011

you are correct, the nurse ought to have seen the patient's wounds herself, then charted her own findings and instructions. failing that, the unlicensed person (you) documented what happened. you could have written, "pt instructed to ...." but that would leave it an open question as to what qualified you to make that recommendation (um, nothing). you could have written, "pt referred to rn for evaluation," without giving names, and handed the chart to the nurse; if the rn didn't follow up, the lack of charting is on her head, not yours.

by doing this, you cover your butt, and while they won't like it, you force them to do what they ought to have done. they got caught out and their comment to you tells me they are more concerned about getting in trouble or disturbing routines than for correcting the practice error of not assessing open wounds in a diabetic (i am making the assumption that these are new, not chronic wounds which they have seen over a long time, in which case next week might be fine).

imagine what would happen if this person developed a good whopping celulitis and sepsis, and in the hospital says, "i told the medical assistant at the office yesterday and he said to come in next week." then when the charting gets reviewed, the only name on it is... yours? really?

i review a lot of office notes, and it's very easy for charting to become very inadequate when it's the same old, same old every day. they need to know that the person down the road won't see it that way and needs to have the same details you'd chart in a hospital... which is everything. "if you don't chart it, you haven't done it" applies to all settings. as to references, you (and they) will find it in every nursing textbook ever written.

ninjago · Dec 14, 2011

You did the right thing. I would chart the same way, names and all. As long as it is objective and truthful. I work in ER and when another nurse helps me and gave the meds or did something to my patient, I chart so and so, RN gave pt meds or did the procedure. The other nurses I worked with do the same thing if situation is reverse.

SHGR, MSN, RN, CNS · Dec 14, 2011

"if you don't chart it, you haven't done it" applies to all settings. as to references, you (and they) will find it in every nursing textbook ever written.

grntea, i agreed with everything you said until the above part, for real. i just have to say, protocol, protocol, protocol...know yours and use them religiously. at our office, we use perry and potter for all "task" things and telephone triage by briggs for triage things. by using these standard protocols, our orifices are covered. even our front desk (unlicensed) people have standards of care for what gets directly transferred to one of the triage nurses. and i see my name in charts all the freaking time! whether or not the issue was ever brought to my attention. sometimes i just...randomly see my name in charts...as in, how was i supposed to know i the doc wanted me to call the patient in a week? hmmm.

also, i have to wonder- the op isn't really unlicensed. she isn't an ma, but as a paramedic, wouldn't there be ramifications to that license if there was a lawsuit or other investigation?

LampsandCoffeeLPN · Dec 14, 2011

Also, I have to wonder- the OP isn't really unlicensed. She isn't an MA, but as a paramedic, wouldn't there be ramifications to that license if there was a lawsuit or other investigation?

I believe in an investigation the person is held to the standards & scope of practice fitting to their function. i.e.- what would another MA be expected to do in the same circumstance seeing as that is what she is doing under the doctor's license in this office, right? (because in the state they are in, their paramedic license was not recognized). Am I correct?

SHGR, MSN, RN, CNS · Dec 14, 2011

In other circumstances (RN working as LPN for LPN pay, APRN working as RN, that kind of thing) the person is held to the standards of their licensure, not the position they are working as. (really poor grammar, there, sorry)

military-mom · Dec 14, 2011

I know it is confusing, I was hired to work the same job as the other LPN's in the office, yet my title is MA. However, my responsibilities far exceeds the Nurses'. My responsibilities include, Telephone Triage, Refills, Referrals and Prior Authorizations, Ordering Supplies, Phlebotomy for all lab patients, Checking in all lab results, Chart prep and a few others in addition to working with a provider. My Ohio Paramedic lisc. is not recognized in Virginia, and my pay reflects that of a Nurse's Aide. The other LPN's only work with one provider. But Hey.....I am lucky to have a job at all.

nurseprnRN, BSN, RN · Dec 14, 2011

"i just have to say, protocol, protocol, protocol...know yours and use them religiously. at our office, we use perry and potter for all "task" things and telephone triage by briggs for triage things. by using these standard protocols, our orifices are covered. even our front desk (unlicensed) people have standards of care for what gets directly transferred to one of the triage nurses. and i see my name in charts all the freaking time! whether or not the issue was ever brought to my attention. sometimes i just...randomly see my name in charts...as in, how was i supposed to know i the doc wanted me to call the patient in a week? hmmm. "

and when someone subpoenas those records three or four years from now, does it say perry & potter or briggs in there, or are they in the office policy book (which will also get subpoenaed)? even if it does or they are, the ma who hands over the chart to the rn to provide assessment and care per office protocol should still chart that s/he has done so. documenting adherence to protocol is what will really save your butt, not just having one. :twocents:

Isabelle49 · Dec 14, 2011

I'm thinking the MD should have decided whether the patient should wait and return 8 days later, not the nurse.

SHGR, MSN, RN, CNS · Dec 15, 2011

and when someone subpoenas those records three or four years from now, does it say perry & potter or briggs in there, or are they in the office policy book (which will also get subpoenaed)? even if it does or they are, the ma who hands over the chart to the rn to provide assessment and care per office protocol should still chart that s/he has done so. documenting adherence to protocol is what will really save your butt, not just having one.

yes, we are supposed to chart "triaged per telephone triage for nurses, briggs abdominal pain (adults) protocol, pp xx-xx"