schej44

Your very welcome.. You can always hold off on a treatment until later in the shift pending a clarification, but NEVER document YOU put the Tx on hold and there's no order to back you up. Any other questions feel free to msg me..

I worked in sub acute and LTC for 10 years.. The documentation that these facilities do is VERY different then the hospital. The example you used about putting an order on hold and documenting that YOU put it on hold is a No No... The documentation should have read along the lines of your assessemt of the wound, the current order, and your call out to the physician for a clarification. After you got the clarification then the documentation should have read that physician clarified order and order was noted and carried out. Or if the physician changed the orders, the documentation should reflect that. Putting an order on hold without a written doctors order is unacceptable to LTC facilities. Always remember.. For everything you do to a patient, you MUST have a doctor's order, have an updated care plan, and the appropriate documentation. If not, the State will hang the facility, and in turn you will be in hot water also. NEVER put something on hold unless there are parameters or you have a physicians order saying to put it on hold.... Also.. every unit has a policy and procedure manual. In there you will find what the policy is for each stage of a wound. Always make sure you get a physician order and document the treatment in your note along with the assessment, and update the careplan.. Hope this helps