I have a huge question. We had a code in our office earlier in the week. Several things went wrong, but I have a question as to who is to chart what. First, should I call the nursing board in my state to find a definitive answer? here's my situation:
Code happens and no one is charting except for a small paper towel as to when drugs were given, times, etc. (THIS WAS NOT AN IDEAL CODE). The lead nurse was in the code before it even started happening. She never charted on word except that 911 called and pt. transported. The doctor did his own documentation and she states that is all we need. I am NOT comfortable with this at all. I think she should document everything from point a to point b with times included and all who were present. She keeps refusing and I told my administrator that I was not comfortable with that. What should I do and what is the correct thing to be done? Should the doctor document and the end, or should she document?
P.S. We are in the process of ratifying our code process, but I need the answer to this question yesterday.
I always do a minute by minute play by play. I chart what drugs were given and when, what rhythms were when we checked, when we held CPR, when we resumed CPR, when we got lines, when we got tubes, size, placement, and number of attempts of tubes and lines, who was there, who dropped them off, when everyone who was there arrived, when we shocked, when family showed up, and everything else that is pertinent...
Mommy TeleRN, RN
649 Posts
ahh thanks Kul I wanted to make sure I wasn't missing something in my understanding :)