Question About Proper Process

[corrections]

In the facility that I work in, the corrections nursing staff is a contract staff through a large medical company that services more than one jail. We are actually not employees of the jail. When our inmates need orders for anything other than pain meds or narcotics, we were trained to put an order in for the medication, start the medication and submit a telephone / verbal order form and chart that the we obtained a telephone / verbal order for the med without ever even speaking to the physician and the physician will sign off on the order later from wherever the physician is located. Is this practice legal? Also, as of today, I have saw management or assistant to the Health Service Administrator with the knowledge of the Health Service Administrator hide or possibly even delete things in an inmates chart to make it look better should a chart audit or chart synopsis ever be ordered. Recently I have noticed that tasks or other things I have put in inmates charts have been disappearing from charts, I don't know what to do. I feel that this is wrong and if the Health Service Administrator is aware of this and permitting this, where do I turn? I have been a nurse for 12 years and never seen anything like this. I recently started corrections nursing approximately 3 months ago and this is different than anything I have ever experienced, I like corrections nursing but don't feel comfortable with these practices, can someone please advise?

[mikethemurse, BSN, RN]

hi, wow...that is not how it works! First, I have worked in several facilities during my time in corrections, and what I am used to is having a protocol book with standing orders for nursing sick call, anything above that the md must write. now depending on the medication I have seen chronic care meds renewed with a "verbal order" as above, but I don't do it personally, I leave the chart to the md and a note asking for him to write the order. At my main job we can print out a list from the pharmacy of meds about to end and then we pull those charts and ask the md to reorder the chroinc care/mental health meds and so on. As far as the messing with charts thing...all I can say is run far run fast and don't look back, because that type of practice is big time bad news bears! Documentation is so important in this area of nursing, and I would be very afraid of stuff like that. Sorry you are dealing with that, but NO it is not the norm nor should it happen ever! be careful, and good luck. please don't let this one company/jail turn you off from what is really a great area of nursing.

[corrections]

Thank you Mikethemurse, RN The way your facility operates sounds like the way things should operate. I am very much considering taking your advice. I am in communications with supervisory staff trying to get changes made and these issues addressed, if they are not corrected soon, I will be taking your advice and looking elsewhere. I think I will stay in corrections nursing if possible, I really do enjoy it after working mainly in hospitals since 2003. It's definitely different but I do enjoy it! Thank you for the reply, I greatly appreciate it!

[mikethemurse, BSN, RN]

Anytime, and good luck!