treatment sheet charting

[armynurse,rn]

I was wondering if anyone can direct my to a resource that talks about what the PCT could legally chart on the dialysis flowsheet? At my clinic I have a tech that often records things like, BP extremely high or records a pt has chest pain when pt was describing sternal pain. I also have a problem with techs recording abnormal vital signs without rechecking even when results are not typical for the particular patient. I would like to give an inservice on legally acceptable documentation. Does any have a resource I could browse?

[Tish88]

I was wondering if anyone can direct my to a resource that talks about what the PCT could legally chart on the dialysis flowsheet? At my clinic I have a tech that often records things like, BP extremely high or records a pt has chest pain when pt was describing sternal pain. I also have a problem with techs recording abnormal vital signs without rechecking even when results are not typical for the particular patient. I would like to give an inservice on legally acceptable documentation. Does any have a resource I could browse?

Here is a good site to check out:

CNNT - Renal Career Fact Sheet

If a PCT is documenting these things such as high BP's and chest pain, they also need to be documenting that they notified the RN on the flowsheet too.

What is your companies policy & procedures for flowsheet documentation? That is another place to start.