Documenting

[RUNZEL]

ON MY SHIFT I FOUND A PATIENT DOWN AT SIDE OF BED. DIED OF SUBDERMAL HEMATOMA THREE DAYS LATER. THE RN ON SHIFT MADE ALL THE NOTATIONS REGARDING THE INCIDEN, EVEN THOUGH NOT THE ONE WHO FOUND PATIENT. SHOULD I HAVE MADE SOME DOCUMENTATIONS REGARDING FINDING THE PATIENT?

[Youda]

Why do you feel that you are screwed? It sounds to me like you are caring and concerned. Did I miss something?

[shannonRN, BSN, RN]

i am also confused. it isn't like you made the patient fall. you found them on the floor. and if you are unlicensed, then i would think that your only responsbility would be to notify the nurse. but i am not a legal eagle. and then again maybe there are surrounding circumstances that we are unaware of that make you feel this way.

to find out if a report was filled out, you could always talk to your manager.

[RUNZEL]

its hard to know what will come of this I just want to make sure nothing is left out in the final analysis, no matter by who. CYB is something i'm learning about

[Youda]

Are you concerned that you will somehow be blamed?

As for making sure that everything is done, approach your DON and ask if the state has been notified. That is required.

[RUNZEL]

i feel the rn recored some ambiguios documentations ,especially not stating who found patient. i have nothing to hide, but i am the person who found the patient, i may have to answer why i personally did not write anything on the incident.

[Youda]

If you are not licensed, you are not only not required to document, but -- forgive the bluntness -- not allowed to document into the legal record. You should NOT have written anything.

The reasons are

(1) you are not legally responsible for the patient. Everything you do, every drink of water you give, is "delegated" by the RN. Although unlicensed staff really don't think of it that way.

(2) you are not taught how to document safely. There are ways to say things, and ways not to say things. There are specific things that must be documented in certain ways. You are not taught to do this.

(3) and this may be the hardest for you . . . you cannot know what you do not know. Unlicensed staff often feel that their nurses are not doing the right thing. Sometimes you are right. But, often that judgment comes because you don't have the training to understand WHY the nurse does what s/he does or doesn't do. It's a communication and understanding gap. Nurses could help by taking the time to explain and listen. But, often, we don't have that time. But, YOU can help by asking questions.

If you are concerned by this, I would strongly encourage you to talk to the RN or your DON, and be willing to listen to what they say. If you still believe something is wrong, call the Division of Aging yourself, you are not only allowed to do this, but you are required.

Good luck to you. And I'm so glad that someone cares and is following through with this tragedy.

[2amigos]

Okay, here goes a "dumb" question--I worked in a group home and we had to document EVERYTHING!! We were "med certified" and had "health care notes", incident reports, daily logs etc... If a client fell (which happens), we had a policy about who to contact when and what to do and then we had to document all that we did... Is it that different in a LTC facility--which is what I assume (yes I know assuming anything is dangerous) is where this incident happened.

I am just curious. I am working on my prerequisites for the RN program and no longer work outside my home, but am curious...

Thanks!

Cheryl Moore