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

[Sadie2016]

I am a new LVN with less than 6 months of experience. 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". My inexperienced and trusting brain agreed to this. Just last week I thought about reviewing the after visit note just to see what the MD was documenting, if his readings were too different from mine only to find out that he had not been documenting anything at all. Now I am freaking out and needing advise on ways that I can address this respectfully with the MD seeming this is technically omitting information from the patient's chart, and eventually I know that my license would be only one in jeopardy...

Would it be a good idea to talk to him about it first or consult the nurse manager? How should I bring it up in a way that it does not seem like I am questioning his decision, or that I am doubting that he is charting it?

Please advise, I would appreciate any words of wisdom

[donsterRN, ASN, BSN]

Yeah, that chart is a legal document. Proper documentation will save your ass. Like others have said, that doc is not likely to defend you if it comes to that.

You job is to assess, document, notify. What the doc does (or doesn't do) isn't your worry.

I think you know the right thing to do. I wish you great luck and success going forward!

[oldpsychnurse]

If the doctor wants you to do something (or not do it), there needs to be a written order, ALWAYS, no matter what the issue is. If he tells you verbally to do something that is so obviously wrong, tell him that you will take it as a verbal order. Write it as a verbal, and until he signs it, continue to document your vital signs. That guy is lazy and if the patient strokes out, he's going to be all "shocked" that you thought he told you not to document the VS and you're going to not only lose your license but probably be sued.

[Here.I.Stand, BSN, RN]

Hugs, OP. Forgive yourself -- you are new, and bumps WILL happen. Remember going forward, that "Dr's orders" are directives for pt care -- NOT for nursing documentation.

[Jory, MSN, APRN, CNM]

You don't need to address it with the MD at all, you need to address this with your manager.

No physician can dictate HOW you chart, the hospital can to a degree (what is appropriate and professional versus what is not), but the chart belongs to the patient and the hospital, not the physician.

This increases liability for YOU and the hospital will hold YOU responsible if the other nurses, physicians, and pharmacy along with other departments, do not have a clear picture as to what is going on with the patient.

To me, its not even a gray area, I would tell him if I take vital signs, they go in the chart, period.

[Jory, MSN, APRN, CNM]

If the doctor wants you to do something (or not do it), there needs to be a written order, ALWAYS, no matter what the issue is. If he tells you verbally to do something that is so obviously wrong, tell him that you will take it as a verbal order. Write it as a verbal, and until he signs it, continue to document your vital signs. That guy is lazy and if the patient strokes out, he's going to be all "shocked" that you thought he told you not to document the VS and you're going to not only lose your license but probably be sued.

I disagree. When it comes to something that controversial, No...I am NOT going to take a verbal order that he can always deny giving you later, but he's going to write it himself. I also would never follow any order that compromises patient safety and if something happens the Board of Nursing nor the hospital will back you up.

Asking you to omit vital signs from the chart is a CLEAR patient safety issue.

[Kooky Korky, BSN, RN]

Wow, what jerks that doctor and manager are!

I don't think I'd say anything to either of them. Just begin charting the VS you obtain and notify the doctor if you get abnormal VS.

I'm wondering if you can make "late entry" notes but they would show that you did not notify the doctor of abnormal VS if there were any, which could call more attention to this matter.

Either way, you are in trouble if any pt suffered harm and I agree with others that neither the doctor or manager will back you up.

Jesus, Jesus, come back soon.

Keep a private written record of the names (doctor and manager) and dates and who said what. Tell no one it exists, never show it to anyone.

I agree you should not accept verbal or phone orders from this doctor. If you do, make sure you have a witness who will co-sign having received orders from him and what the orders are. Otherwise, refuse. Tell him why. Tell him that the way he wanted you to deal with the VS has caused you not to trust him. Or just tell him it is policy that you will accept VO or TO only in emergencies. Otherwise, he must fax them or write them himself in the chart/electronic record.

He really needs to be reported to his licensing Board. He is not safe and he is willing to take you down with him - or, really, make you a substitute for his shoddy work. I know we sometimes can safely take shortcuts, but this is not one of those times. So as I'm thinking about this further, I guess you really do need to take this up with someone in authority. Be prepared to be disciplined, fired, made the bad guy/the target, reported to BON, etc. They will all be trying to scramble for cover and make you the scapegoat.

He has regard only for his own neck - doesn't care about you or his patients. Wow, scary stuff.

If I were on the disciplinary committee of the state Board of Nursing, I would not cause you to be disciplined. I'd commend you for reporting.