Questions about Problem charting at night

[downsouthlaff, LPN]

Ok so heres my question. As the 3-11 Nurse , when i get a complaint of congestion at 9 oclock pm, or pain, and lets say i have the means to treat it ex. PRN pain meds , or decongestion medicine, do i still need to document physician noified in my nurses notes when documenting the problem or can i just document something of the sort of " C/O of congestions noted , adminstrered PRN Mucinex. Verbalizes relief of congestion. Encouraged fluids, continued to monitor." Would this be appropriate it , because i had the means to correct the problem without further orders ? Or do i need to still notify the physician and document that he/she was notified. Any advice ? How do you guys handle such situations. This is a long term care nursig home. Thanks!

[loriangel14, RN]

Why would you notify the MD just because someone asked for a PRN medication?

[RescueNinjaKy]

I don't think you will need to notify the physician if it's just prn meds unless there's a reaction, a change or imminent change of condition.

[CT Pixie, BSN, RN]

I worked LTC for years. We never had to notify the MD when giving a PRN for pain/fever etc. We documented it in our notes..the problem, our intervention and the results.

We did pass along in report that Mrs B c/o congestion and was given a PRN decongestant, afebrile blah blah blah.

The only time we did notify the doc is if there was a PRN for something like fever. The MAR might say something like, notify MD if fever is XXX or higher. We'd still document like I said, add that the MD was notified, put in any new orders the MD gave or put 'no new orders'.

[downsouthlaff, LPN]

Thanks everyone! No loriangel i would not. I was just wondering if there was a C/O congestion, and difficulty sleeping because of it , or a C/O nausea and if i had a standing order or a PRN order for Zofran or phernergan would i just administer , document and monitor since i have tge means to fix the problem or would i notify the MD of the change of condition anyway. Even though i put pain up there this is not about them asking for a prn narc.

[MunoRN, RN]

If the patient has already left you a plan in the event of a "change in condition" such as congestion, why would you need to notify them? They've already said that if the patient complains of congestion, give them mucinex, that's what the PRN is.

[downsouthlaff, LPN]

I understand your logic and i thank you all for answering this qhestion. It was just a new nurse concern. I know that state surveyors can be very picky in the LTC and audit charting of floor nurses to a T. Im just looking at it another way. Our medical director who gives us standing orders pretty much writes the same standin orders so every one of out residents pretty much have the same PRN orders as far as OTC meds. I was just wondering have any of you ever been pulled months later by a state surveyor and asked ! "Well didnt you feel this naseau was something you should have notifiedb the physician over ? But i really do see where u are all coming from and i appreciate the advice !