Updating H&P via phone

[citylights89, BSN, RN]

I remember verbal/telephone orders being covered in nursing school, but not this. I work in the OR and if we have an inpatient that is scheduled for surgery, a complete H&P has to completed within 30 days of admission and updated within 24hrs of surgery. Well, today, the last time someone updated it was 2 days ago, so before we could proceed to take the patient from the unit to the OR, we had to have documentation of the H&P. The unit nurse paged the surgeon and had him call back. He said that he had seen the patient the day before (even though it wasn't documented) and that nothing had changed. I documented that "All Systems Remain the same", verbal (but changed to telephone), his name, my name, the date and time. Now, I'm wondering if I did the right thing. Has anyone ever faced this issue?

[citylights89, BSN, RN]

Now that I sit here and think about it, I should have paged the resident on call. Oh geez . I'm still on orientation and was by myself and wasn't sure what to do.

[HouTx, BSN, MSN, EdD]

Live and learn, huh? You have already realized your mistake - hopefully, everything went well & I'll bet you don't do it again - right?

There are very compelling reasons for all the "tightening up" of surgical processes over the last few years. It is based upon clear evidence of what is needed to keep patients safe and avoid mistakes. So, when you're faced with surgeons who are ticked off and have a 'you're not the boss of me' attitude about following the rules (pre-op documentation, timeouts, counts, etc)..... just hold your ground. Don't make any exceptions. Follow all the rules exactly as they are written in the policy or procedure.

Yeah, we understand that the docs are in a hurry but it really isn't about them.. it's about the patient & our primary job is to protect our patients.

[citylights89, BSN, RN]

Yes, I hope nothing comes of it, but I did learn from my mistake. The nurse in the ICU unit "Said" that the surgeon had seen the patient the day before, but must have forgotten to note in in the chart. I took her word for it and thought, at the moment, that the surgeon verifying that there were no changes was ok. Man, this first year of nursing is rough. Sometimes I feel like I'm just running around like my head is on fire and hoping that I don't run into anything and set anything else on fire.