why record lab results in the nurse's note

[Pediatricjo]

Does any other facility require you to enter non-critical values into the nurse's note? We have now placed a section in the nurse's note for entering abnormal lab values, did you call the doctor & what resulted, why you didn't call the doctor. There is possibly a new policy coming that would require us to enter each lab value. At this time there is no definition of if it is each & every lab value or a particular out of range but not critical value. We have a place to enter critical lab values & what we did about it.

[nurseprnRN, BSN, RN]

It may be the RM people just went to a workshop on defensive charting-- they learned that nobody can say you didn't see them if you have to record them somewhere. Personally, though it's a pain, I know it WILL force people to actually look at labs, and over time this will improve your staff's clinical ability.

[amoLucia]

Question - will there be some hard-copy of values from the lab??? I'm always concerned when data is in multiple places and one of those places requires a written note by staff.

There's too much room for error if data is mis-recorded or omitted. If the chart goes to court and one documented source identifies one specific value while another source identifies a different value, who will be right??? An astute legal team could recognize the discrepancy and then question the writer's accuracy and possibly, competency. And since the facility's P&P hasn't been followed to the letter, administration may well fail to support the staff person for any legal fallout. (Hence, the need for personal malpractice!)

I do like the fact that staff is being forced to acknowledge lab values, but I think this approach is risky.

I work LTC and I've seen instances of poor data communication. Not good, but this duplicative documentation may not be the way to go. Just need a better corrective way - just my opinion.

[Pangea Reunited, ASN, RN]

I would hate that. I agree that it leaves too much room for conflicting data to be recorded. Even when I have a critical, I chart, "informed of potassium level" without including an actual number. And I disagree with anything that makes me feel like I'm in preschool all over again. I don't need to be forced to look at labs or vital signs or anything else.

[Morainey, BSN, RN]

That sounds like a real pain. I usually note abnormal or critical values in my notes but if I notified our docs of every low H&H I'd be on the phone all freakin' day.

[rncat2000]

At our hospital we are required to record only critical lab results and what doctor we spoke to about it and if there were new orders or not.

We have a policy in place that when there is a critical lab result we have 1 hour to notify the doctor with that result.

[morte, LPN, LVN]

Electronic charting, there should be a way to "import" data. paper charting this indeed would/could be a problem; as in anything that is required to be "in put" by hand in more than one place. More room for errors.

Question - will there be some hard-copy of values from the lab??? I'm always concerned when data is in multiple places and one of those places requires a written note by staff.

There's too much room for error if data is mis-recorded or omitted. If the chart goes to court and one documented source identifies one specific value while another source identifies a different value, who will be right??? An astute legal team could recognize the discrepancy and then question the writer's accuracy and possibly, competency. And since the facility's P&P hasn't been followed to the letter, administration may well fail to support the staff person for any legal fallout. (Hence, the need for personal malpractice!)

I do like the fact that staff is being forced to acknowledge lab values, but I think this approach is risky.

I work LTC and I've seen instances of poor data communication. Not good, but this duplicative documentation may not be the way to go. Just need a better corrective way - just my opinion.

[tewdles, RN]

I agree that it sounds like the nurse responsible for this has learned something new and is trying to implement as best can.

However, the nurses actually responsible for the documentation should be a part of this discussion. Nurses are professionals who should not have their professional practice dictated to them relative to this issue, IMHO. There seems to be lots of room to have some intelligent discussion at your facility about the risks, dangers, costs, to this plan and provide some thoughtful alternatives to meet the goals.

Everyone will be much happier, from management to bedside staff to patients if solutions to problems are achieved collaboratively when possible.

[classicdame, MSN, EdD]

We have computer charting. When labs are resulted the nurse has to click on each line indicating the report was acknowledged. Each line will be the name of the test, like CBC, not each value. It is possible to check them all at once. The OP post sounds terribly time consuming.

[KelRN215, BSN, RN]

At our hospital we are required to record only critical lab results and what doctor we spoke to about it and if there were new orders or not.

We have a policy in place that when there is a critical lab result we have 1 hour to notify the doctor with that result.

When I worked in the hospital, it was the same. There was a spot on the electronic flow sheet under "safety" for nurses to chart that they were notified of critical lab values and then notified the physician and what was done. The lab was required to call the bedside nurse with critical lab results and we were then required to notify the physician within 30 minutes. Sometimes what the lab called about was something we weren't going to do anything about anyway... i.e. an oncology patient admitted with fever/neutropenia has an ANC of 200... that was technically still a critical value according to our lab, but it was also the criteria for discharge.

I didn't often include lab results in my nurses' notes but our software did have a function where we could import the day's VS, labs and I&O into our notes.

[MunoRN, RN]

It's appropriate to document critical labs and what was done as well as assessments of labs, but just copying lab values from one place to another is an all around horrible idea.

In terms of legal "defensive charting", double charting is a huge no-no. One of the best weapons a lawyer has is documented proof of an error, even if it's unrelated to the case. Our policy is to chart critical labs, who was notified, when, etc, but we never chart the lab value itself, if we do we get a "nastygram" from risk management. That a critical WBC count was received at 1900 and Dr. X was notified is appropriate, but the most accurate source for the actual value should be used.

Whenever information is copied from one place to another it becomes by definition less reliable. We used to copy lab values out of the computer onto a rounds sheet for morning rounds. After too many times where patients were treated for another patient's lab values, we stopped doing that.

People don't become any more familiar with a patient's labs by copying them from one place to another. Most people can't simultaneously copy from one place to another and also analyze that information. There have been experiments where people are given words one at a time to copy down, after copying down an entire story word by word they still had no idea what the story was about. When we used to copy labs down onto a rounds sheet I still had to then go over the patient's labs separately. All copying them down did was took time that I could have spent analyzing their labs. Documenting your assessment of labs however is much different, it's totally appropriate and useful to chart "worsening anemia overnight per labs".

[Georgia peach RN]

Our facility has a Critical Lab Value Log, when there is a Critical Lab value, Lab call the Nurse, Nurse documents in Critical Lab log, the time notified critical lab, Dr. notified and time, then on the paper copy of the lab we have a stamp we stamp it with and write in Dr. name and time notified and sign/Int. We do not document this in the pt chart. Though if I am the primary nurse I will document in my pt chart critical lab value rec'd Dr. notified and new orders noted or some other similar entry on my nurse note but I never document the value.