To chart, or not to chart

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Ok nurses! We need some answers..... I have been a nurse for four years now, and now our company has this new policy. I, along with other "seasoned" nurses, are questioning this policy. Ok, so something happens and it cannot be handled by the nurse per company policy and rules, therefore the nurse informs the manager or "boss", which is a nurse as well. Is it proper to chart that the correct people have been informed of situation? (This is not an occurence, we are aware that is something different.) But we have been told not to chart that any other person from management has been involved in any care (making us feel that if legal issues were to come up, management would be free and clear when we weren't able to handle situation in the first place). Please some feedback, because now we are confused about how to chart these situations.. Thanks.

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Specializes in SNF, 2 year s hospital.

WOW, I acutally couldnt prove that I notified a supervisor that my patient's blood from the blood bank was late. When it came down to the verbal coaching the supervisor never recalls being called. So from that point on Ive made a point on documenting to whom the information is given. Like you said it seems as though everybody else is free and clear. Why are "they" special and exempt?:confused:

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Specializes in Certified Med/Surg tele, and other stuff.

How could you not say they were notified? Otherwise wouldn't it look like you didn't do XYZ? Am I missing something?

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When I contacted the supervisor of anything, I charted it. Period.

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Specializes in Certified Med/Surg tele, and other stuff.

Eeny..Meeny...Miney....Mo, who's license is gonna go?

(it wouldn't be mine!);)

Contact your BON. Maybe they can help.

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Specializes in LTC, Memory loss, PDN.

Is that new policy in writing?

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Specializes in Certified Med/Surg tele, and other stuff.
Is that new policy in writing?

If you find it in writing, keep a couple of copies in case it disappears when **** hits the fan.

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Specializes in Trauma Surgical ICU.

OMG,no way.. You chart the problem and what you did.. Period.

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Specializes in LTC, Psych, Hospice.

Nursing 101:

If it isn't charted, it didn't happen.

I think you need to continue to CYA!

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Specializes in Emergency/Cath Lab.

I would bring as many people into it as I could. That is such a nice way of saying we dont want any responsibility and can blame it on you if something happens. I dont mind ever dragging more people into my charting to cover my own butt.

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Specializes in Hospice.

I always chart under collaboration!

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always chart. in 7 years, the people involved won't remember specific conversations, so you have to cover yourself. it doesn't necessarily have to be detailed; you can just chart "d/w _________, supervisor/manager/whoever." in my hospital, we have to make a note when a patient falls, and part of that note is charting that you spoke with the doc, patient's family member, and that you notified the patient care supervisor, manager, and CNS, even if only by text-page. you are ultimately responsible for your own license.

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