minderaser804

It's not so much the charting of notifying a specific doctor that I'm inquiring about, but more of a CNA.... she's in school for the moment, but on a consistent basis practices OUTSIDE of her scope of practice. I've brought it to the management's attention, but nothing has been done about it. This was the scenerio....a baby ( I'm a pediatric nurse on a med-surg floor) was very agitated and upset when the vitals were taken. The HR was 149 for a 2 yr old, which is not detrimental, considering the circumstances under which the vitals were taken. She charted the HR and then annotated that "So and So, RN, was notified". I totally understand the importance of charting and charting correctly, however, there is a fine line of "over doing it". What really peeves me, is when it's charted that I was notified and NOTHING was ever said to me, or better yet, I'm in a near crisis situation and they (the techs) find it necessary to tell me of something so silly when I'm in the big middle of something. If the patient has a known history of abnormal vitals, then that's their baseline. If they are fit to be tied and completely po'd and the vitals are higher, then that's to be expected. If they have had NORMAL VS up until that point, then by all means, tell me and right away. This "CNA" has been caught telling patients of their medications, their discharge instructions and the list goes on. I've tried to confront her in the most delicate way possible, but it seems to not be working. I even approached her about throwing out names in charting when it wasn't necessary. I guess she went to managemnt, because there was an email a day later about "charting with the names of you told". I guess it really chapped me that she did that, but even more so, because I think I'm right on this. I've tried to go online and find documentation DO's and DON'Ts but, I'm coming up empty handed. Guess I'm going to have to check out BAM or Barnes & Noble and read up on it. But at the same time....every facility has their "OWN" policies that they go by, regardless of what is common for nursing.......thanks for all the input, my wonderful colleagues!!! :)

I could have sworn that I was told once not to include names of individuals when charting. ( i.e. a CNA charts that "so and so, RN" was notified of a vs that wasn't even critical. ) I thought it had something to do with legal issues and names don't necessarily have to be dropped. Does anyone have any info on this kind of thing? It has become somewhat of an issue where I work.