Procedure Documentation Question

[amcgraw]

What is your policy on documenting during cardioversions (or other cardiac procedures) when anesthesia is present and administering sedation? We do propofol for cardioversions. I have recently been told that I am no longer supposed to document vital signs when anesthesia is present. This presents too much grey area for my liking and I feel that it would not stand up in a court of law. Please tell me how you handle it in your facility? Thanks!

[dianah, ASN]

You might take this up with your Risk Management dept, who could possibly clarify for you "how it would stand up in a court of law."

We prepare our pts for the procedure, and often anesthesia personnel are not present at the very beginning of it; they arrive for their sedation part, perform it, and when the pt is sufficiently recovered that the anesthesia personnel feel they are no longer needed, they leave and the pt is again our responsibility.

Our VS are recorded automatically on the MacLab, for the Cath Lab procedures, so when we print out our nursing notes/report, all the VS are there anyway, regardless if anesthesia personnel have recorded their own.

So, we record the vitals up until the time anesthesia accepts resposibility for the pt.

I will usually observe if they have taken their own VS monitoring sheet out, and are using that to record VS.

I then ask if they want me to record any VS or if they need any report, or if I can help in any way.

If they answer no, then I document "patient monitoring turned over to M. Smith, Anesthesiologist."

After anesthesia person leaves, I note I have resumed care of pt, "after receiving report from M. Smith, Anesthesiologist."

As I mentioned, via the MacLab system, the VS are still recorded at all times.

My gut feeling is, if the Anesthesiologist or CRNA is sedating, s/he is the one responsible for the patient monitoring (conversely, when I sedate for a TEE or a Cath or a pacemaker implant, I am the nurse responsible for monitoring the pt).

But I'm still watching. :)

[amcgraw]

Thanks for your response. That is pretty much what I have been told to do going forward for cardioversions. I just thought I would bounce the idea out there to be sure it was consistent with the practice of others. We too have McKesson to do our cath procedures etc, so it is only really an issue during cardioversions.

Deep down though I can't help but still feel that if we are not "allowed" to document during the time they are sedated, then I would rather not even be in the room - "If you didn't document it, then you didn't do it" mentality scares me too much.

In the meantime, I will continue to document "Care of patient airway and sedation assumed by anesthesia, etc"

Thanks so much!