Nurses notes on lab results ?

Posted
by downsouthlaff downsouthlaff, LPN Member Nurse

Specializes in Nursing Home. Has 9 years experience.

I am an LTC nurse. I’ve practiced as an LPN in LTC my whole 8 year career as a licensed nurse. I recently started at another facility with young floor nurses, a young ADON, and we share a different opinion on documenting results of labs. Most of the nurses at this facility, receive the lab work, notify the physician, and then proceed to retype the lab results into a nurses note. For ex if the lab result is a CBC or CMP they will type all the details of the report into a note.  The WBC lebel, RBC, all the way down the report until the nurses note is basically a copy of the report. I however throughout my whole career have always been taught that interpreting labs is outside of a nurses scope of practice therefore it doesn’t belong in our nursing progress notes. For example, my nurses note would read

“Received result of CBC from lab. Notified MD of the result, no new orders given,-J. Smith, LPN” 

And that would be it I would leave it at that because I was always thought that the nursing responsibility wants receiving lab work is to notify the physician of the results, and saying only what you need to say is better than saying to much. I just wanted to get the opinion of other experienced LTC nurses

Hoosier_RN, MSN

Specializes in dialysis. Has 29 years experience. 3,588 Posts

I'm with you, but I know others like the ones you describe. To me, this takes way too much time to type the note with all the details. All that is needed is " CBC results received, MD notified, no new orders". Now that said, if there is a critical result contained in that, example Hgb 6.4, then I would definitely note that specific result and the provider response. Hope this helps. 

The young nurses doing this are also likely the ones who complain of not having time to get anything done, or never get out on time

JustBeachyNurse, RN

Specializes in Complex pediatrics turned LTC/subacute geriatrics. Has 12 years experience. 1 Article; 13,952 Posts

Unless a critical value (and we have a template) your version is our policy and my personal practice.  “Reviewed (lab tests) with attending (or covering provider ) no new orders”.  “Received call from Jane Smith at ABC Hospital hematology lab, critical lab: +ESBL, contact iso precautions initiated, infection control noticed, attending physician reviewed sensitivity and xyz orders received read back and entered”

Golden_RN

Golden_RN, MSN

563 Posts

It makes no sense and is a total waste of time to copy all results in your notes.  If anyone wants to know what the values are, they can look at the lab report.  Totally agree with Hoosier and JustBeachy above.

 

ComeTogether, LPN

Specializes in Keeping my head above water. Has 7 years experience. 1 Article; 2,157 Posts

Less is more, for sure. The exception would be grossly abnormal results or other reasosn which are obvious to the reader 

“Critical hemoglobin of 5.3; NP notified - NNO” 

essentially means “when this patient goes out later via 911 you can’t say I didn’t warn you” 

 

obviously I’m being tongue in cheek; I’d most likely be calling that out after they’re out of he building but you get the idea. 

Kim Nahrgang

Kim Nahrgang

Specializes in Staff Development, Long Term Care, Assisted Living. Has 32 years experience. 3 Posts

Waste of precious time. Time that could be spent with the actual resident.