Sensitive Charting

[sanctuary, BSN, MSN, RN]

I had an opportunity to assess a restraint situation and discovered a series of major violations of our policy and nursing procedure. I carefully charted all the issues as I found them, and included the patient's physical condition, and statements. All efforts were made to remain factual and nonjudgemental. I feel that there were issues of abuse that should be investigated, and so I sent copies of my notes to the appropriate departments. My nursing supervison says that, while I behaved correctly in protecting the patient, and taking photos of the bruises, that I should not have put it in the patient's medical record. Where else should it have gone??? Does it sound like an attempt to protect the institution, rather than the patient, or am I just being paranoid?

[NurseyBaby'05, BSN, RN]

Maybe attached to the incident report. It's not part of the chart, but it is official documentation. One should have been filled out in addition to your thorough charting.

[CharlieRN]

At any facility in which I have worked, admissions or accusations of wrongdoing are never entered into the chart. The proper place for these is an incident report. If your facility does not have an incident reporting proceedure then they would go in a letter or memo to your superior, possibly with copies to other involved departments.

What goes in the chart is just what happened, what you did, the patients response to treatment your plan of care and assessment of what needs to be done, without non-nursing judgements, or commentary. There is no need to mention that a policy has been violated, or a proceedure preformed incorrecty.

Further there is never to be a mention of the incident report in the patient chart. Patient charts can be supeoned. Basicly, a lawyer who is searching for grounds for a case can get any paperwork he can prove exists. Every patient has a chart, so he can get that. But unless he can show a judge evidence that an incident report exists, he can't demand to see it.

Your duty to be a patient advocate means you should help your patient heal and give care toward that end. It does not mean you make it easy for them to sue your employer or your coworkers. That would be legal advocacy, not nursing care, and as such is outside your role. You have a duty to protect both the patient and the institution. Mistakes get made in health care, just like every other human endevour. You will make them too, sooner or later.

Incident reporting is in the nature of constructive criticism. It is the means by which the institution improves itself. If the situation involves violations of laws, not just policy, you may have a duty as a citizen to report this. I would only do that after having retained legal counsel for myself. If you do something like that you may have made yourself an enemy of your employer. Acting against the best interests of your employer is most likely grounds for termination.

I'm really surprized that your employer didn't cover this during orientation.