Report Boards

[Adele_Michal7, ASN, RN]

Does anyone work in homes where the patient's parent, etc has a marker board where they require you to do a report on it before leaving. You know, write a line or two for each hour you are there? Vitals, etc.

I can see how this is handy and I've had homes in the past where I didn't mind, because 1.) it was semi optional (giving a verbal report was ok) and 2.) They didn't want or need a lot of info on it.

This family I sub for now on the weekends DEMANDS a practical nursing note written down, in addition to report, in addition to our carbon copies of our nurse narratives they get left to read.

It's a little overboard especially when I get lectured by the "head nurse" on the case for "not writing enough."

And I won't even write in those report books/comm books. My agency doesn't even allow those, they can be trotted out in court. Shudder.

[brillohead, ADN, RN]

We have a marker board, but it's more for non-report communication.

One section is for "things we need" (supplies that are running low), one section is for notes (like time that PRN meds are administered so the next person knows when to administer the next dose), and one section is for keeping track of patient info, such as when the trach and Mic-Key were last changed, last BM, etc.

But writing a duplicate narrative nurse's note when you've already written one... what's the point? I could maybe see keeping track of how many times the kid is suctioned per hour, so that the next shift can see at a glance if there's a big change in frequency/amount, but as for the rest, I'd just write "see nurse's notes" and leave it at that.

[smartnurse1982]

Sounds to me as if they are trying to catch one of the nurses in a mistake.

They sound like the type that like to take people in court.

It could be that they can't understand some nurse's handwriting.

I did not know communication books could be trotted out in court?

[caliotter3]

Communication books are considered part of the record and have been part of court cases. That is why agencies caution nurses about what to write in these books and how to write it. They are not for idle gossip and childish comments directed to others, even though some nurses insist on this.

[ceebeejay]

Never had this experience. I have had communication books, but only to keep track of what the child had eaten. Mostly the communication goes toward the nurse not the other way around. Like what was going on with the patient, when otc meds were given by the parent.

[eeffoc_emmig]

My current case has a dry erase board for listing supplies/meds needed. We recently started a log book at the demand of the parents. The company is fine with it. I. Am. Not. I keep it short sweet and to point. I make sure that info exactly matches my nursing notes.

[amoLucia]

Sounds to me as if they are trying to catch one of the nurses in a mistake.

They sound like the type that like to take people in court.

It could be that they can't understand some nurse's handwriting.

I did not know communication books could be trotted out in court?

Just what I was thinking. And there's a lot of potential for mistakes when so much duplication is avail. Just RIPE for scrutiny by a lawsuit-happy family and their lawyers.

And just FYI - I, too, was always told that if a lawyer learns of ANY piece of documentation (even if it's a scribble on a greasy paper napkin from Burger King), it can be subpoena'd and included into evidence. This includes bedsheets (where we all have written BPs and wound measurements) and our own little personal daily note journals.

Any legal folk out there can correct me if I'm wrong, but I heard this loooong ago from a very reliable source.

[systoly]

i think the biggest problem would be if something directly pertaining

to pt. care was written as secondary (non official) documentation, but

omitted from the official nurse notes

my take on this is if there's a problem with reading the carbon copy

ask staff to press harder or use different pens, if this doesn't fix it,

get a scanner or copier

about the not writing enough - what does she want

it's not about quantity, one of my coworkers writes down every stroke

of the comb or toothbrush, do you know how long it takes to get

the pertinent info? (she is an excellent nurse otherwise so this is easy to overlook)

[realnursealso/LPN, LPN]

Sounds like the typical over jealous parents. Their child is not in ICU, if that was needed, they wouldn't be home. Over charting is nuts and most times it is not relevant. Don't really have any advise, agency won't make them back off. Guess you will have to choose your battles. Wonder if eventually they will have a storage problem?

[Adele_Michal7, ASN, RN]

Sounds to me as if they are trying to catch one of the nurses in a mistake.

They sound like the type that like to take people in court.

It could be that they can't understand some nurse's handwriting.

I did not know communication books could be trotted out in court?

That is exactly the people they are. I think my agency wants to get rid of them. I believe they used another agency and possibly a hospital.

[CloudySue]

I have a mom that can't be bothered reading the nurse's notes, she insists on us writing down the highlights of the night (how vitals were, how many times suctioned, diaper changes, etc.) but she's such a mess she seldom provides us with note paper on which to write, so we end up scribbling on the back of old envelopes that litter her kitchen island. When I write these notes, I give her what she wants, but I do NOT sign them in any way, nor do I put the day or date on them. I don't know if that'll help me at all but I want to be as little help to a lawyer as possible. I'm there once a week, and like I said, she's messy. I'll often find that same note floating around the kitchen table with the others from the week before, so I take that opportunity to tear my note up and toss it in with the used diapers.

I also never sign after anything I write in communication logs.