Narcotics Documentation

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I was working in a surgeon's office where he had no formal inventory of narcotics. I had asked and asked for help in instituting a policy, but never received that help. I quit the job, but in retrospect I see that there was no space in which to sign the medication off every time it was given. There was no sig line. There was no initial box. The only place on the form was a spot where all of the staff present was documented. When the nurse oriented me to the position I asked her about this, and she said that because we were the only nurses there, it was presumed who gave the meds.

When I discovered that the non-nursing staff was administering meds, I just began initialing in any spot I could.

I am so afraid that I am going to get in trouble for improper documentation despite the fact the office did not provide appropriate chart forms.

I am so mad and remorseful that I did not do an about face the moment I saw how poorly that office was run! :angryfire

HELP!

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My current home health agencies do not document controlled substances either. I don't like the situation and have told the supervisors so.

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Always, always protect yourself. It will be your license on the line if (unfortunatly) there was a lawsuit. How irresponsible of that surgeon.

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I Know...shame on him! But I am responsible for MY practice, and I was so focused on all of the other violations, which were huge, that I never focused in on that piece. I am almost certain I will lose my license over this. I reported his practice to the DOH. 26 years of pretty darned good nursing care down the drain. I'm just sick.

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What do you mean you will lose your license over this? I understand that you gave meds that were not documented correctly due to that facilities charting policies however YOU are the one that reported it and you left due to the unsafe conditions.

Has the DOH threatened your license over this? If I were you I would talk to someone on the BON in your state about the situation. I don't think the DOH can take your license away, only the BON can. I doubt the BON would take your license for this, but I don't know what the laws are in your state. IF it does come to the BON considering sanctioning your license or taking it go to that board meeting and explain yourself. You have 26 yrs of experience don't let them try to take your career without knowing all the facts.

Best of luck and I hope nothing happens to your license over this. Keep us posted.

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I just think that because my charting will be the only way they know what was given and when, I will be cited for following the form. But my friend who works in nursing law says that I was made to conform to the guidelines of the workplace, and that I had no control over that piece. She also said that if the nurse who oriented me charted the same way, then my practice was not a deviation from the norm in that setting.

I still have a bad feeling about it.

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I agree with the friend that works in nursing law. You followed the procedures in place at that practice, you didn't do anything wrong. Good luck.

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Thank you. I fear I need it. I still have not heard anything from the nursing commission. Somehow I don't think that no news is good news.

That scumbag! I hope he gets what's coming to him...if not in this life...the next.

And to think all I wanted to do was to care for my patients in a safe and appropriate manner.

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