Qustion about meds and charting

[kwagner_51]

I am working in LTC right now, and had a pt ask for PRN MOM. The order is written for 30 cc's. She requested and received 15 cc's. I charted on the back of the MAR that she received 15cc's. I was told today by the charge nurse for that unit, that I had to chart as though she had taken the 30cc's.

Is this ethical? To me, I feel like I am lying and it really bugs me.

Thanks for your advice!!

_____________________________________________

In His Grace,

Karen

Failure is NOT an option!!

[TexasPediRN]

I would only chart 15mls. The pt has a right to take half the dose, no way would I write 30ml if thats not what I gave. I dont beleive that would be right to chart the 30ml in any setting.

[CoffeeRTC, BSN, RN]

I would initial it and circle it then write an note that pt only took 15 ml per request. Next step is to get the order changed to 15 ml if thatis what she will take or look for another med option for consitpation.

Only chart what is done!!! I'd question her reasoning too.

Good to see you are working in LTC!!

[Noryn]

It feels like a lie because it is a lie. You did everything correct. I am not sure how the nursing home charges for things such as MOM but if they are only taking a half dose and you say they are taking the full dose (and they charge for the full dose) then it is fraud. And you are responsible.

I have said it many times, sometimes you get in trouble for doing the right thing--such is life. If it were me I would go to the charge nurse, explain that I cannot document this in good conscience, if that doesnt work then go to the DON.

I get into arguments like this approx. every 2-3 months. I finally get frustrated and say, "Ok lets call the board now and see what they say." Needless to say they usually back down.

It is just frustrating to hear someone give advice or tells you to do something that is BLATANTLY WRONG.

[~Anne~]

Definately only chart what is given! or in this case not given. Pts have refused meds countless times or only wanted to take half of whats ordered. All you can do is chart what you gave and that the pt refused the rest. Sometimes the pt refuses the entire medication , what are you gonna do chart that the pt took it anyway??? I hope not. Just make the docs aware and document in the chart , especially if its a med the pt should really be getting. MOM is not really a big deal , but you shouldn't chart what you didnt give.

[CoffeeRTC, BSN, RN]

Just wondering...why is she telling you what to chart? Does the charge nurse review all documentation?

I've seen this before...I can see reviewing documentation for completeness and maybe for general content if you are new, but just remember...you always chart what you do. It is your license...not theirs.

[LPN1974, LPN]

You did nothing wrong. Don't worry about it.

The patient can take only a half dose if she wishes.

In response to Noryn.......The LTC's that I've worked in, "stock" certain meds. MOM, tylenol, ibuprofen......there were alot that was just floor stock can't remember all of them now.

The home I worked in was notorious for wanting a charge slip made out for everything that was given to the patient, but for some reason, I didn't have to make a charge slip when I gave a floor stock med.

If you used a 4x4 to clean a wound and a bandaid to put over it, you had a charge slip that had to go in a book. But they didn't do this on floor stock meds.

I think there is some law that says certain meds have to be stock and the NH has to provide it.