Not entering vital signs in pt chart per MD orders...

Double-Helix, BSN, RN · Apr 1, 2017

Huh? Way too many red flags here. Document your assessment and vital signs in the patient's chart. If the MD want's to go back and make an addendum note, they can do so. If you get push back from the MD, escalate to your manager.

Meriwhen, ASN, BSN, MSN, RN · Apr 1, 2017

And if something happened to this patient and the charting was reviewed, I guarantee that MD would throw you under the bus ("I didn't tell OP that. Why didn't OP chart the pressure like any nurse is expected to do?").

I agree with Double-Helix. You chart your assessment and if MD wants to addend it, then let MD do it and have the responsibility for changing or omitting vital signs on his ***.

cleback · Apr 1, 2017

If it's above 140/90, you will likely have to call and notify the doctor anyway, so tell him then that you don't feel comfortable leaving it undocumented. Just say it's policy.

MunoRN, RN · Apr 1, 2017

I would politely remind the doctor that intentionally omitting relevant information is not something I can do, regardless of his request to do so. I would also notify your manager that a doctor has asked you to falsify charting.

macawake, MSN · Apr 2, 2017

Recently I got caught up in a situation with a MD who asked me not to chart the patient's blood pressure if it was above 140/90. He said something along the line of "If it is above 140/90 just write in on a sticky note and not on the chart, I will document it after talking to them about it during the visit".

I can't think of a single legitimate reason for this request. What's there to "talk about" (I assume to the patient?)? No amount of talking on the part of the physician will alter the blood pressure reading that you got, so there's no reason to delay charting it.

OP, I realize that you are new and it can be difficult to question orders but whenever an order or prescription is unclear or seems not to make sense, you need to ask for the rationale for it when it's given. Both for your sake and for the sake of your patients. What would you have done if the patient had a blood pressure of 210/110? Written it on a sticky note? If this had happened to me I would have notified my manager regarding the physician's "unorthodox" request.

**canoehead, BSN, RN** · Apr 2, 2017

I've seen notes get "lost" when the physician didn't want something in the chart. Be sure to notify your manager in writing.

lpn164 · Apr 2, 2017

What EMR do you guys use? He is trying to prevent losing a quality measure which will effect a bonus from the hospital. They keep reports on all of my doctors and the goal is to have something like

KatieMI, BSN, MSN, RN · Apr 2, 2017

1). A physician cannot tell you how to do your NURSING job. You are doing yours like he is doing his. Next time, just politely refuse. "I am sorry, sir, but I can't do this, it's my job. Please write order for parameters if you wish".

2). I entirely understand why it was done - the doc was either just plain lazy or possibly fed up with endless calls "as per policy" if BP went up a nudge above what is written there. It doesn't make such a request legal, though.

3). As things are standing right now, you need to speak with your management ASAP, before someone else did it. Be honest, and I hope nothing will happen.

4). When you feel a bit more comfortable with your job, get together with your management and find out why this question would ever arouse. I bet that either the doc is known far and wide for being a complete nut (then it is your management's job) or there is really some ridiculous policy requiring nurses to call for pressure 141/89 because some piece of paper says that the tolerated max must be below 140/90, either number. Then it is up to you guys to change that so everybody become happier.

Good luck!

smf0903 · Apr 2, 2017

I agree with everyone else, that is way weird and I'd be documenting my assessment no matter what he said. I'd politely let him know that you document assessments and vitals and if he'd rather you not document them then he can kindly put an order in the chart to not document BPs above 140/90 thankyouverymuch.

I'm sure if you ask him to document that he told you NOT to document that will be the end of that :yes:

Sadie2016 · Apr 2, 2017

Thanks everyone for your responses. I had previously notified the manager when he first asked me to start doing this and she said it was fine for me to write it down for him as long as he was ultimately documenting in on the chart.. For a few weeks after that it did not cross my mind to go back to the chart and review them to see if he had documented it because why would you not trust the MD that you work with on his word.. If he said he was going to chart it, I believed him he would.. Ultimately to find out he was not doing so.

So now not only have I realized that he is not to be trusted on his word, but that my "nursing judgement" really failed me when I followed his orders without questioning.This is one of the first things they teach us in school. I am very disappointed and frustrated with myself at this moment.

macawake, MSN · Apr 2, 2017

If he said he was going to chart it, I believed him he would.. Ultimately to find out he was not doing so.

I am very disappointed and frustrated with myself at this moment.

Live and learn. OP, don't beat yourself up. You can't go back in time and change what has already transpired. Having gained this experience, I think that the next time a physician (or some other coworker) makes a request that seems a bit "off", you'll find it easier to stand your ground.

I had previously notified the manager when he first asked me to start doing this and she said it was fine for me to write it down for him as long as he was ultimately documenting in on the chart..

If you informed your nurse manager about the physician's request and that is the response you got it seems to me that your manager is aware of this practice and that's a warning sign to me. I obviously think that your manager's response was unsatisfactory. She is burdening you with the responsibility of having to track your patient charts in the future (after your shift has ended and perhaps even after a patient has been discharged) to make sure that the vitals you took are in fact being belatedly recorded by another healthcare professional.

As others have pointed out, I very much doubt that the physician or the nurse manager would come to your defense if something were to happen to the patient and your lack of charting became a focus of an investigation.

I think that the fact that you did go to your nurse manager and ask for advice shows that your gut instinct (your gut instinct no doubt nudged along by what you've been taught in school and your common sense) was correct. You knew that this request was a bit odd. In the future trust your instincts and cover your behind :)

Good luck going forward!