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Nursing judgement and computer documenation

Posted

Specializes in ICU/CCU, PICU.

I was just reading another post regarding interventions that should have be completed while waiting to talk to a physican. For instance, getting an ekg, enzymes on a new chest pain patient while waiting for a callback from the physican.

How do you all think computer documention is going to affect this? In my current hospital, we are not allowed to put in orders (and we get in trouble for it too), but yet things won't get done without the orders. Do you put in your own orders? Do you have to attach a physican to it?

BluegrassRN

Has 14 years experience.

It's the same as before. We enter the orders under the physician, for him/her to co-sign later. In my facility, we have protocols for a lot of events (EKG for CP, etc). In a rapid response, we can enter pretty much for anything the responding team recommends while awaiting the physician's arrival, again according to our protocols.

If you don't have protocols for chest pain, symptoms of hypoglycemia, hypoxia, etc, your facility needs to get those going. I suspect they are already in place, though.

BYW, they told us in our classes that ONLY physicians would be entering orders. THEN later, after implementation, they said that only applied to day shift. If we call someone at night, the nurses are expected to enter the orders.

BrnEyedGirl, BSN, MSN, RN, APRN

Specializes in Cardiac, ER. Has 18 years experience.

Same here,..we enter the orders, per protocol, under the docs name, he signs them later.

msjellybean

Specializes in Emergency. Has 4 years experience.

My facility has a chest pain protocol, where we're allowed to order cardiac enzymes & a stat 12 lead while waiting to hear back from the doc.

ObtundedRN, BSN, RN

Specializes in Critical Care. Has 6 years experience.

In our critical care division, we have lots of standing orders. So we can order it ourselves. It doesn't even need a doc to co-sign since one already signed off on the standing order set.

As for the documentation in the computer, it is entered as being written by the primary doctor. This is done because lab results and other stuff is sent to that doctor's PDA or computer for review later. So if you enter another doctor's name, the correct doctor has to search for it and the wrong doc gets results and left to figure out why.

In our critical care division, we have lots of standing orders. So we can order it ourselves. It doesn't even need a doc to co-sign since one already signed off on the standing order set.

As for the documentation in the computer, it is entered as being written by the primary doctor. This is done because lab results and other stuff is sent to that doctor's PDA or computer for review later. So if you enter another doctor's name, the correct doctor has to search for it and the wrong doc gets results and left to figure out why.

I've wondered about this when other doctors get involved. One of my supervisors once told me to put both names on the order.

BYW, they told us in our classes that ONLY physicians would be entering orders. THEN later, after implementation, they said that only applied to day shift. If we call someone at night, the nurses are expected to enter the orders.

Yep, we were told the docs would have to enter the orders unless they were scrubbed in, or they were driving. :lol2:

How long do you think that lasted?:uhoh3: