Should I have charted different?

littlemissfit · Jun 17, 2015

MS was very bad to begin with @ start of shift which is why I called MD in beginning and she came and saw the pt initially.

Anna S, RN · Jun 17, 2015

I have charted similarly in the past. You charted the truth. I see nothing wrong with it.

RN403, BSN, RN · Jun 17, 2015

As long as you state facts and not opinions you will be fine.

Laurie52 · Jun 17, 2015

A year back when I first started as a new grad, fresh off orientation, I had a patient who was going into respiratory failure in a rehab for which the MD refused to send out. She/respiratory and supervisor looked at this pt at the beginning of the shift and only ordered IVP lasix. I called her 5 times that night bc the patients mental status was declining. I could have called a RRT but the only people who would've shown up would have been the MD the supervisor and respiratory the same people I was already talking to. (Yes looking back now I should've called anyways). But After calling MD 5 times and refusing to do anything until the morning (on night shift) I called the supervisor with my concern. He said the same thing she did. Long story short although she was holding her O2 sat, they sent her out in the am and was admitted to ICU. In my note during the night and repeated calls I wrote "RN concerned for lack of response from MD called
X3 because of... (Sx/sy). supervisor and charge RN made aware with primary RNs concern. Was told by both MD and supervisor to wait until morning for CXR."
In school they briefly touched on charting, but I heard from other nurses after you aren't supposed to chart pointing fingers. But I wasn't sure how else to get across I was trying everything to get her sent out. How should I have charted that? Was I wrong to chart that?

I would have charted the patient's complaints, pertinent assessments and your interventions. When you document that you felt that the physicians response was not appropriate to the situation, my next question to you would be: what did you do about this? Did you call the medical director or upper management? Perhaps instead of doing everything to get the patient sent out, you could document all your interventions to stabilize the patient.

littlemissfit · Jun 17, 2015

We wouldn't have had the resources to stabilize the patient, she needed to be intubated and they don't do that at that facility. Which is why I was trying to get her sent out. After I called the MD I called the supervisor and got the same answer. Who else do you call when it's the middle of the night and these are your higher ups? Later my manager told me to call him in the middle of the night. But I was pissed and no longer work there. Bc that was unacceptable to me.

wanderlustnurse88, RN · Jun 17, 2015

I would just chart everything. MD called at 1950 with xyz concerns. MD stated at 1955 xyz. No new orders received at this time. Those are the times when you just need to keep objective charting and chart what you did and who you called. I've had nights with unstable pts on an acute care floor (have up to 7 pts on a night shift), where the chart stays open to the nurses notes all night and I just keep adding to it each time I do something.

jadelpn, LPN, EMT-B · Jun 17, 2015

I would not use words like "RN concerned". I would, as a pp pointed out, chart what you did assessment wise, your interventions and response of patient. "MD notified at _____, of patient's continued resp. distress,no new orders. Charge RN notified__________. Pt continues to show s/sx of ___________,

Lasix __________mg given per MD order, MD aware of little output (

This could be a learning thing as well--when do you call a RRT? When do you send out patients?

All really good questions. And every facility as a different policy on this.

mvm2 · Jun 17, 2015

Lack of response from MD does not seem appropriate. He did respond to you...just not in the way you wanted him to. Like the others said report the times you contacted MD and write out what his orders were and report exactly what you did for patient. Remember less descriptive words and what I calling feeling words as possible.

sallyrnrrt, ADN, RN · Jun 17, 2015

We wouldn't have had the resources to stabilize the patient, she needed to be intubated and they don't do that at that facility. Which is why I was trying to get her sent out. After I called the MD I called the supervisor and got the same answer. Who else do you call when it's the middle of the night and these are your higher ups? Later my manager told me to call him in the middle of the night. But I was pissed and no longer work there. Bc that was unacceptable to me.

I use my critical thinking skills, and nursing judgement, and after ineffective directions from doctor etc, I pick up phone and call ems, with the evolution of patients care at acute care hospital, ie intubation/icu......doubt you would get much flack, the doctor would have appreciation of your assessment saving their bacon....if said doctor got in a tiff, I would say you did not have patient on palliative.....and seeking increased level of care for a de compensating patient is not practice of medicine, it is patient advocacy....

sallyrnrrt, ADN, RN · Jun 17, 2015

I would not use words like "RN concerned". I would, as a pp pointed out, chart what you did assessment wise, your interventions and response of patient. "MD notified at _____, of patient's continued resp. distress,no new orders. Charge RN notified__________. Pt continues to show s/sx of ___________,
Lasix __________mg given per MD order, MD aware of little output (
This could be a learning thing as well--when do you call a RRT? When do you send out patients?
All really good questions. And every facility as a different policy on this.

this is great direction for you, thanks jade

Rocknurse, MSN, APRN, NP · Jun 17, 2015

Chart everything. If you have computer charting then write a digital note or write a paper one and enter it in the physical chart. If you feel something is off then it probably is, and often I have written a note to myself when I've gotten home with details in case something comes up later and you can't remember details. Most important is to document how you found the patient, assessment, vitals and then your intervention. State what time you called the doc and the state of the patient at the time, and then the result of your intervention (assess, plan, implement, evaluate). If you're not getting the answers you want, be your patient's advocate. Call the next rung up the ladder. If you feel intimidated or not supported then call the nursing supervisor and have her deal with it. One thing you can't do is accept the inaction of another and so it's up to you to make the next move and you must document as such. In a court of law, just saying "I called so and so therefore I'm off the hook" will not fly. Definitely say "I called so and so and he did not answer so I called Mrs X). Sounds like you did the right thing. However, if the vitals would have worsened I would have kept calling until they did a stat CXR but I'm stubborn like that. In the ICU we call it CYA. Cover...your.....