Nurse overdocumentation

[Hemichordate]

Does anyone have to deal with nurses that document every little encounter or change that involve you as a physician? For example, I have to deal with a lot of nurses who document things like, patient's potassium was 3.1, per Dr. X, will administer Kdur. Or patient's urinary output has been progressively decreasing over the last 4 hours, per Dr. Y, will continue to monitor.
Or something like that. It just feels like nurses want to be free of any responsibility/blame if things go wrong, even in the most minor circumstances.

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[deleted877019]

Does anyone have to deal with nurses that document every little encounter or change that involve you as a physician? For example, I have to deal with a lot of nurses who document things like, patient's potassium was 3.1, per Dr. X, will administer Kdur. Or patient's urinary output has been progressively decreasing over the last 4 hours, per Dr. Y, will continue to monitor.
Or something like that. It just feels like nurses want to be free of any responsibility/blame if things go wrong, even in the most minor circumstances.

I'm an outsider (not a US doctor), but couldn't help replying that both of these examples of nursing documentation are appropriate and not overkill.

 

[Raryn]

The only ones I mind is when they paged and documented about the wrong doctor.

9pm Patient with chest pain, paged Dr. Raryn, no response.

When my shift ended at 6.

 

[AdmiralChz]

Does anyone have to deal with nurses that document every little encounter or change that involve you as a physician? For example, I have to deal with a lot of nurses who document things like, patient's potassium was 3.1, per Dr. X, will administer Kdur. Or patient's urinary output has been progressively decreasing over the last 4 hours, per Dr. Y, will continue to monitor.
Or something like that. It just feels like nurses want to be free of any responsibility/blame if things go wrong, even in the most minor circumstances.

It's really annoying when this happens, but remember you are the physician and in charge of the care of the patient. They are not. If it really bothers you, address it in your own progress note (e.g. urinary output decline expected given cessation of diuretics with euvolemia). But don't be snarky or sink to their level or it will get worse.

If someone is being disruptive/argumentative with their notes as in Raryn's example, you can consider addressing it with a chief resident or your staff but remember that nurses band together and you do NOT want to get on their bad side unless you love getting ridiculous hammer pages ("Dr. Chz, wanted to let you know Mr. Y only ate about a quarter of his lunch and had some belly pain.").

 

[PlutoBoy]

Does anyone have to deal with nurses that document every little encounter or change that involve you as a physician? For example, I have to deal with a lot of nurses who document things like, patient's potassium was 3.1, per Dr. X, will administer Kdur. Or patient's urinary output has been progressively decreasing over the last 4 hours, per Dr. Y, will continue to monitor.
Or something like that. It just feels like nurses want to be free of any responsibility/blame if things go wrong, even in the most minor circumstances.

That is appropriate documentation since it was your order.

I almost got a nurse fired when she documented that she discussed something with me when she didn't. She called me about X and documented she discussed X and Y with me. I looked into the chart and opened her note by chance and saw that. I immediately confronted her and she was very apologetic so that was the end of it.

 

[gutonc]

I wish the RNs at my primary hospital would document anything...at all...ever. We don't even usually get on/off shift status notes. They sign out to each other on paper and that's it. Want to find out what happened overnight? Either show up/call before the night nurse leaves, or hope the day RN was paying attention during signout (variable).

 

[LucidSplash]

OP, sounds like to routine nurse documentation to me. Their job is to note things like that and make sure the doctor is aware. Most of the time, it isn't within a nurse's scope of practice to make changes based on lab values or changing UOP. That's your job. So they are required to report it to the physician and document any new orders undertaken as a result. Not sure why this stuff bothers you so much. It is par for the course of being a physician - the responsibility DOES lie completely with you.

 

[anonperson]

Does anyone have to deal with nurses that document every little encounter or change that involve you as a physician? For example, I have to deal with a lot of nurses who document things like, patient's potassium was 3.1, per Dr. X, will administer Kdur. Or patient's urinary output has been progressively decreasing over the last 4 hours, per Dr. Y, will continue to monitor.
Or something like that. It just feels like nurses want to be free of any responsibility/blame if things go wrong, even in the most minor circumstances.

Of course they want to be free of responsibility. They aren't in charge. They will only step in when they think they can save the day from the "dangerous doctor" from doing something they think is dangerous.

This is how most nurses document. Just get used to it and move on. It is annoying but benign.

At least they communicate with you. In fellowship, it was like pulling teeth to get an update from the nurses or for them to update their nursing notes on the EMR on a timely basis. Usually it was done right at the change of shift, so 12 hours of info condensed in crappy note.

 

[20gauge]

OP:

I am a nurse who routinely documents my conversations with MDs. You would probably find my documentation to be overkill. Many MDs I work with like it and have thanked me for my attention to detail, but I realize it's not for everyone.

Sadly, defensive medicine exists because the conditions under which we work demand it. Just as a doctor does not want to be sued, I don't want to be pulled into a lawsuit either. It is my job to notice things such as abnormal labs and declining urine output and communicate them to the doctor. If I communicate them to the doctor, I will document it to protect myself. I am not attempting to throw the doctor under the bus, but rather to document that I have done my job.

Regarding your statement that it feels like we "want to be free of any responsibility / blame if things go wrong", you're absolutely right. I don't have the ability to act on abnormal findings, only report them. This puts me in an unenviable position. I'm sure you can understand that.

 

[obgyny]

Does anyone have to deal with nurses that document every little encounter or change that involve you as a physician? For example, I have to deal with a lot of nurses who document things like, patient's potassium was 3.1, per Dr. X, will administer Kdur. Or patient's urinary output has been progressively decreasing over the last 4 hours, per Dr. Y, will continue to monitor.
Or something like that. It just feels like nurses want to be free of any responsibility/blame if things go wrong, even in the most minor circumstances.

Actually most of the time, nurse documentation is helpful. As someone above mentioned, it can be helpful to piece together overnight events when the day nurse is unaware. Especially on a busy service like Labor & Delivery, it is helpful when the nurses document the sequence and timing of events, especially during emergent situations like shoulder dystocia or crash c-sections that comes in handy when I get a chance to document myself later on. I also encourage the nurses to document observations of patients I'm concerned are potentially drug-seeking or have hostile family situations, etc. since they spend more time with the patient.

However, I have seen nurses using documentation as a way of being passive aggressive. They will document the exact time and number of times they paged you for non-emergent things, when I was stuck in back-to-back c-sections. Once while a postop c-section patient was getting into bed, she sort of slipped and landed on the bed on her bottom (not a real fall...), but the nurse calls me and DEMANDS I come evaluate her right now, even though the patient wasn't requesting to see a doctor and had no complaints... because the nurse claims she will be written up for a "fall" incident. Since I was dealing with unstable preeclamptics and several upcoming deliveries on the floor, I told the nurse I would come to see the patient later on when I have a chance. She documented that I refused to come see the patient .

 

[NotAProgDirector]

OP:

I am a nurse who routinely documents my conversations with MDs. You would probably find my documentation to be overkill. Many MDs I work with like it and have thanked me for my attention to detail, but I realize it's not for everyone.

Sadly, defensive medicine exists because the conditions under which we work demand it. Just as a doctor does not want to be sued, I don't want to be pulled into a lawsuit either. It is my job to notice things such as abnormal labs and declining urine output and communicate them to the doctor. If I communicate them to the doctor, I will document it to protect myself. I am not attempting to throw the doctor under the bus, but rather to document that I have done my job.

Regarding your statement that it feels like we "want to be free of any responsibility / blame if things go wrong", you're absolutely right. I don't have the ability to act on abnormal findings, only report them. This puts me in an unenviable position. I'm sure you can understand that.

I agree that nursing documentation is incredibly helpful. However, it turns out that documenting that you alerted someone to a serious problem (lab, urine output, vitals, etc) doesn't actually protect you in a medmal situation. Invariably, the plantiff's side argues that your documentation clearly demonstrates that you noticed the issue and realized it was important. Hence, when nothing was done about it, you should have alerted someone else -- contacted the doc again, or called your charge/lead, etc. What actually happens in situations like this is that this type of documentation tends to make defending cases much harder, especially ones where no real malpractice happened (but now your note suggests that it did). And if the hospital loses a case based on your note, it's not going to protect you.

This is a very common misconception.

 

[20gauge]

I agree that nursing documentation is incredibly helpful. However, it turns out that documenting that you alerted someone to a serious problem (lab, urine output, vitals, etc) doesn't actually protect you in a medmal situation. Invariably, the plantiff's side argues that your documentation clearly demonstrates that you noticed the issue and realized it was important. Hence, when nothing was done about it, you should have alerted someone else -- contacted the doc again, or called your charge/lead, etc. What actually happens in situations like this is that this type of documentation tends to make defending cases much harder, especially ones where no real malpractice happened (but now your note suggests that it did). And if the hospital loses a case based on your note, it's not going to protect you.

This is a very common misconception.

I can see how this can be a problem if I do not hear back from the doctor and assume that merely documenting it is sufficient. That is throwing the doctor under the bus. I respect that the doctor is likely dealing with something emergent if he/she does not respond right away, so I use my clinical judgment and either call another provider or the Rapid Response Team to address the concern.

So what is the best way to proceed? If I don't document that I communicated my findings, I worry that I will be called into question (which happens often enough that it is concerning). Is there another option?

 

[cbrons]

I can see how this can be a problem if I do not hear back from the doctor and assume that merely documenting it is sufficient. That is throwing the doctor under the bus. I respect that the doctor is likely dealing with something emergent if he/she does not respond right away, so I use my clinical judgment and either call another provider or the Rapid Response Team to address the concern.

So what is the best way to proceed? If I don't document that I communicated my findings, I worry that I will be called into question (which happens often enough that it is concerning). Is there another option?

If its a mid-level, then call the physician.

If its a resident, then call the attending (or whoever the more senior resident listed for that patient is).

If its an emergency, call RR team.

I dont see any other options.

 

[Crayola227]

the nasty ones say, "MD paged, awaiting orders." Update: "Contacted MD to come bedside, still awaiting arrival."

this after you have called them back immediately and explained why you don't need to come bedside

or of course, they page you again an hour later, you give in and go beside, and of course it's not reflected in their notes, and the whole thing was just as stupid as you knew it would be

 

[Wordead]

I don't have a problem with clinically relevant items - potassium, urine, etc. My problem is with "family in room. updated family" and nonsense like that just ****ting up the EMR.

 

[20gauge]

If its a mid-level, then call the physician.

If its a resident, then call the attending (or whoever the more senior resident listed for that patient is).

If its an emergency, call RR team.

I dont see any other options.

The reality is that nurses are often called into question for not documenting communication of critical findings to the attending. If there is a code on a patient, a chart audit is performed and gaps in documentation are identified. Nurses are being held accountable for these gaps. We are just as frustrated as you are.

I don't want to write it any more than you want to read it, but I'm repeatedly being threatened from above. It's a reality.

 

[20gauge]

the nasty ones say, "MD paged, awaiting orders." Update: "Contacted MD to come bedside, still awaiting arrival."

this after you have called them back immediately and explained why you don't need to come bedside

or of course, they page you again an hour later, you give in and go beside, and of course it's not reflected in their notes, and the whole thing was just as stupid as you knew it would be

This is passive aggressive and throwing the doctor under the bus. I don't do this because I'm not an a**hole, but I have seen it done before. Wrong on many levels.

I respect the doctors I work with. I am not one of those nurses who is a self-professed die-hard "patient advocate" saving the patient from the hands of the evil doctor. I don't wear scrubs with cartoon characters on them, and I resent being taught in nursing school that nursing is an altruistic profession. I am working for a paycheck. Sure, I will be good to my patients, but I would be good to my clients too if I was a banker.

 

[Psai]

the nasty ones say, "MD paged, awaiting orders." Update: "Contacted MD to come bedside, still awaiting arrival."

this after you have called them back immediately and explained why you don't need to come bedside

or of course, they page you again an hour later, you give in and go beside, and of course it's not reflected in their notes, and the whole thing was just as stupid as you knew it would be

I've had this happen once, I spoke with the nurse and never had any trouble with this again. Like other people are saying, it doesn't protect the nurse and actually puts a target on the doctor. I have also been the victim of people putting my name down for "md aware" when I wasn't anywhere near the hospital and missing "sepsis screens" for a patient chilling with a baseline hr of 90 and I'm sleeping at home.

But I do think that the nurse documentation in the OP is appropriate.

The documentation I hate is the nonsense that PT and OT put in their note that make them completely unreadable when all I want to know is if the patient is cleared for sar. Also chaplain notes by chaplain "residents" (?). Everyone and their mothers wants to put something in the chart and it's difficult to wade through the morass of neverending garbage.

 

[Hemichordate]

I apologize if I made it sound as if nurses do this all the time, and I do feel that many documentations by nurses, with or without reference to the MD, are appropriate. In hindsight, I suppose the two I mentioned are appropriate too. I think I've just been on the receiving end of a number of documentations that Crayola mentioned in his or her post earlier, especially the ones that are passive/aggressive.

 

[FutureInternist]

The only ones I mind is when they paged and documented about the wrong doctor.

9pm Patient with chest pain, paged Dr. Raryn, no response.

When my shift ended at 6.

I have had that happen so many times, that I started calling the nurses at home after their shift ended and "highly suggested" that they change the "false information" in patient's medical chart.

Helps a little but every time a new class of nurses starts, it peaks again.

 

[AlmostAnMD]

As long as it helps to construct a defensible chart. We have a few nurses that over-document things that outright contradict MD.

Eg: psych doc leaves note in chart saying patient not suicidal, can go home
ED doc leaves note in chart saying same, agrees with psych note

Nurse note (this is almost verbatim to what she wrote): psychiatrist and MD both agree patient safe to discharge. Writer strongly disagrees and feels patient may harm herself when she returns home.


Now, nothing happened but if something did that would be excellent fuel for a lawsuit fire. There have been numerous occurrences of this happening here and eventually, by sheer probability, the nurse will be correct and someone will be hung out to dry

 

[Psai]

As long as it helps to construct a defensible chart. We have a few nurses that over-document things that outright contradict MD.

Eg: psych doc leaves note in chart saying patient not suicidal, can go home
ED doc leaves note in chart saying same, agrees with psych note

Nurse note (this is almost verbatim to what she wrote): psychiatrist and MD both agree patient safe to discharge. Writer strongly disagrees and feels patient may harm herself when she returns home.


Now, nothing happened but if something did that would be excellent fuel for a lawsuit fire. There have been numerous occurrences of this happening here and eventually, by sheer probability, the nurse will be correct and someone will be hung out to dry

That is completely inappropriate, the nurse should be reported to the nursing board for practicing medicine (although she won't lose her license despite what 95% of floor nurses say) and fired immediately.

 

[20gauge]

Nurse note (this is almost verbatim to what she wrote): psychiatrist and MD both agree patient safe to discharge. Writer strongly disagrees and feels patient may harm herself when she returns home.

This is not just documentation overkill, it is practicing outside one's scope. I hope you followed up with his/her manager. I know it's time consuming but it won't stop until it is brought to someone's attention.

 

[WheezyBaby]

As long as their documentation is accurate idgaf. It just reflects the exchange. If you're uncomfortable with your decision making being reflected in medical record, it should give you pause about your decision. When it comes to addressing calls about pain or agitation, what I feel is appropriate is, not uncommonly, not quite what the nurse wants. This occasionally leads to passive aggressive documentation. "MD awared patient pain 10/10, refusing appropriate pain management, reports will monitor patient suffering at this time". Hyperbolic, but you get the gist. Tends to happen in cases where the true desire of nursing seems to be "make this patient stop bothering me". In those situations, which are rare, I'll drop a note myself.

 

[Apollyon]

To swing the pendulum completely the other way, at my first EM job out of residency, at the university hospital, as a rule, when a critical value was notified, the chart note was "critical value received, no orders given". This became a race for me, and I caught it once - potassium of 3.1, and PO repletion orders given. I told the nurse that their documentation was wrong, as orders WERE given. This mattered, because, with IBEX/Picis, one could not edit a signed note, so, a brand new note had to be written, which directly contradicted the prior one. I didn't make a stink of it - it was just what it was.

Now, if a nurse even writes a note, I'm happy. I was happily surprised the one day when I had a per diem nurse that documented regularly, and the notes made sense to me, and were useful. What clouded the issue is that she is HOT (active lingerie model), but not a one-trick pony, and, actually, a supremely competent nurse. The story in the book is MUCH better than the cover.

Also, as a final note, it SEEMS like the more a nurse documents (to distract from patient care), the weaker the clinical skills. The incompetent take half (or more) of the shift to try to throw the doc under the bus.

 

[mvenus929]

I was happily surprised the one day when I had a per diem nurse that documented regularly, and the notes made sense to me, and were useful. What clouded the issue is that she is HOT (active lingerie model), but not a one-trick pony, and, actually, a supremely competent nurse. The story in the book is MUCH better than the cover.

So, you were more surprised that she was competent because she was attractive?

 

[Apollyon]

So, you were more surprised that she was competent because she was attractive?

No, as I said, it clouded the issue. She is that hot, that it stops one for a moment. If I could work with her every day, my job would be simpler, happier, and easier. Being easy on the eyes is just a bonus.

 

[Siggy]

Does anyone have to deal with nurses that document every little encounter or change that involve you as a physician?

For the most part I don't mind it... and being able to click on the "Physician Contact" notes in our EMR makes it easy to see if anything happened overnight (constipation, pain, subtly changes in condition). I rarely have issues where it feels like they're trying to hang me out to dry. However just this week I had to drop a quick note clarifying that I didn't "hold" the levemir... but that our inpatient pharmacy closes at 11pm, so the levemir wasn't available and I wasn't going to give -more- insulin because I'd rather have some hyperglycemia overnight than have the patient bottom out over night with no one noticing it.

 

[Precedexed Out]

OP, sounds like to routine nurse documentation to me. Their job is to note things like that and make sure the doctor is aware. Most of the time, it isn't within a nurse's scope of practice to make changes based on lab values or changing UOP. That's your job. So they are required to report it to the physician and document any new orders undertaken as a result. Not sure why this stuff bothers you so much. It is par for the course of being a physician - the responsibility DOES lie completely with you.

You are partially wrong. I have seen on numerous occasions where nurses document resident physician decisions in an inappropriate manner. By this I mean a subtle, but obvious jab jab because the resident physician isn't following the nurse's perceived normal algorithm. Some nurses are super annoying, acting as if they know more than the resident. Sure, maybe the interns at the beginnin of the year because nurses have some pattern recognition skills, but a second or third year resident knows vastly more than a nurse.

 

[Precedexed Out]

For the most part I don't mind it... and being able to click on the "Physician Contact" notes in our EMR makes it easy to see if anything happened overnight (constipation, pain, subtly changes in condition). I rarely have issues where it feels like they're trying to hang me out to dry. However just this week I had to drop a quick note clarifying that I didn't "hold" the levemir... but that our inpatient pharmacy closes at 11pm, so the levemir wasn't available and I wasn't going to give -more- insulin because I'd rather have some hyperglycemia overnight than have the patient bottom out over night with no one noticing it.

Perfect example of nurses lack of medical knowledge. A little hyperglycemia for one night isn't going to kill anyone, the same can't be said for hypoglycemia.

 

[Precedexed Out]

As long as it helps to construct a defensible chart. We have a few nurses that over-document things that outright contradict MD.

Eg: psych doc leaves note in chart saying patient not suicidal, can go home
ED doc leaves note in chart saying same, agrees with psych note

Nurse note (this is almost verbatim to what she wrote): psychiatrist and MD both agree patient safe to discharge. Writer strongly disagrees and feels patient may harm herself when she returns home.


Now, nothing happened but if something did that would be excellent fuel for a lawsuit fire. There have been numerous occurrences of this happening here and eventually, by sheer probability, the nurse will be correct and someone will be hung out to dry

Without documenting why the nurse believes the individual may harm themself, it shouldn't carry much weight, although I understand this likely isn't the case in the real world. This nurse should be disciplined and reported to the nursing board, nurses aren't doctors and aren't allowed to practice medicine. The nurse's medical opinion doesn't matter so there is no reason to document it.

 

[NYCGuy86]

Without documenting why the nurse believes the individual may harm themself, it shouldn't carry much weight, although I understand this likely isn't the case in the real world. This nurse should be disciplined and reported to the nursing board, nurses aren't doctors and aren't allowed to practice medicine. The nurse's medical opinion doesn't matter so there is no reason to document it.

While I do agree that that note is inappropriate, are you saying that the nurse stating that in their opinion, the patient may harm herself is "practicing medicine"?

 

[Winged Scapula]

You are partially wrong. I have seen on numerous occasions where nurses document resident physician decisions in an inappropriate manner. By this I mean a subtle, but obvious jab jab because the resident physician isn't following the nurse's perceived normal algorithm. Some nurses are super annoying, acting as if they know more than the resident. Sure, maybe the interns at the beginnin of the year because nurses have some pattern recognition skills, but a second or third year resident knows vastly more than a nurse.

I'm confused why a self-professed medical student is correcting a Vascular Surgery fellow over an argument she didn't even make.

@LucidSplash never said that nurses never documented inappropriately or in a passive aggressive manner.

 

[20gauge]

While I do agree that that note is inappropriate, are you saying that the nurse stating that in their opinion, the patient may harm herself is "practicing medicine"?

As a nurse, I do not have the training to determine if a patient is likely to harm themselves after discharge. I can note that they are trying to harm themselves in my presence and communicate that to the doctor, but determining their likelihood to harm themselves in the future is outside of my scope.

 

[LucidSplash]

I'm confused why a self-professed medical student is correcting a Vascular Surgery fellow over an argument she didn't even make.

@LucidSplash never said that nurses never documented inappropriately or in a passive aggressive manner.

What @Winged Scapula said.

I came back from Mexico for this? I need another strawberry mojito.

 

[LucidSplash]

While I do agree that that note is inappropriate, are you saying that the nurse stating that in their opinion, the patient may harm herself is "practicing medicine"?

To say a nurse is "practicing medicine" is shorthand for "practicing medicine without a license" or "acting outside their scope of practice." @BingoBaby123 is not creating an equivalency between the nurse's documentation in the case of the psychiatric patient and those of other clinicians, they are saying that that documentation is outside the nurse's scope of practice and could end up with a charge of practicing medicine without a license, which is the official terminology for when a nurse exceeds their scope of practice.

It's legalese.

 

[Jublybubly81]

That is completely inappropriate, the nurse should be reported to the nursing board for practicing medicine (although she won't lose her license despite what 95% of floor nurses say) and fired immediately.

I don't agree that the nurse' s opinion can be classed as practicing medicine. How about you recognise that some nursing practitioners have a lot of experience that may just help you one day. Many patients would be grateful of a nurse showing such diligence and I expect they would like a doctor that made the correct calls based on best care rather than fear of litigation or fear of admitting that a nurse may actually know a bit more about patient care than you.

 

[Psai]

I don't agree that the nurse' s opinion can be classed as practicing medicine. How about you recognise that some nursing practitioners have a lot of experience that may just help you one day. Many patients would be grateful of a nurse showing such diligence and I expect they would like a doctor that made the correct calls based on best care rather than fear of litigation or fear of admitting that a nurse may actually know a bit more about patient care than you.

a) the nurse's opinion is irrelevant. if they have concerns, they can bring it up with the doctor but it definitely does not belong in the chart.
b) the practice of medicine is obvious and nurses are overtrained in how to avoid even using medical terms and instead use "nursing diagnoses"
c) the nurse's charting in that example clearly increases risk of litigation without any benefit. discharge a potentially suicidal patient is inconsistent with fear of litigation

 

[Jublybubly81]

a) the nurse's opinion is irrelevant. if they have concerns, they can bring it up with the doctor but it definitely does not belong in the chart.
b) the practice of medicine is obvious and nurses are overtrained in how to avoid even using medical terms and instead use "nursing diagnoses"
c) the nurse's charting in that example clearly increases risk of litigation without any benefit. discharge a potentially suicidal patient is inconsistent with fear of litigation

To answer your points
A) nurses opinion is not practicing medicine.
B) if you disagree with nursing training then you should raise this with an appropriate authority. The nurse fulfilling her training is not practicing medicine.
C) the nurse charted her opinion and also made sure the doctors opinion was noted, this is not practicing medicine.

 

[20gauge]

To answer your points
A) nurses opinion is not practicing medicine.
B) if you disagree with nursing training then you should raise this with an appropriate authority. The nurse fulfilling her training is not practicing medicine.
C) the nurse charted her opinion and also made sure the doctors opinion was noted, this is not practicing medicine.

A) As a nurse, I am trained specifically NOT to chart my opinion because it is not of value. This would be along the lines of documenting that my patient is "annoying" - sure, I may find him/her annoying, but that is my opinion and not fact. Charting the patient's observable behaviours is encouraged, not my opinion of them.

B) Psai does not disagree with "nursing training," he disagrees with your interpretation of it.

C) See A.

 

[WholeLottaGame7]

To answer your points
A) nurses opinion is not practicing medicine.

So, you're of the opinion that things like "I think this patient should be on a beta-blocker" or "I think this patient needs their gall bladder removed" wouldn't be practicing medicine?

 

[FutureInternist]

0015 - pt taken to restroom
0020 - pt back from restroom
0035 - pt's wife called. Updated her
0047 - pt asked for orange juice, this writer (whats up with saying that instead of "I") gave him one juice box
0052 - pt coded but dont ask me for how long, what meds were given, how many times he was shocked
0100 - RoSC so BED RAILS UP AND TV REMOTE W/I REACH

The important stuff gets lost in the plethora of inane things that get documented.

 

[mvenus929]

I work with two systems. Currently, on our Cerner product, the nursing notes are kept in the flowsheets and you have to actually look for them. They are often useful when the overnight person has no idea what actually happened overnight.

In Epic, the nurses document in the actual notes section. Sometimes this is useful--if there is a baby born overnight that I didn't attend the delivery of, the nurses will put in a note listing all the historical information I need, time of birth, and what the name and PCP are. Sometimes, it's not very useful--when the nurse puts in a note saying she drew a bili, then a second note informing me of the results and that I didn't want to change anything about the plan of care. For the latter, I really wish there was a 'nursing' note, so I could screen these out and read important progress updates from consultants, etc, rather than the hundred nursing care plans.

 

[NYCGuy86]

A) As a nurse, I am trained specifically NOT to chart my opinion because it is not of value. This would be along the lines of documenting that my patient is "annoying" - sure, I may find him/her annoying, but that is my opinion and not fact. Charting the patient's observable behaviours is encouraged, not my opinion of them.

B) Psai does not disagree with "nursing training," he disagrees with your interpretation of it.

C) See A.

As a nurse, do you avoid using "medical terms"? Did your training involve avoiding "medical terms"?

 

[NYCGuy86]

As a nurse, I do not have the training to determine if a patient is likely to harm themselves after discharge. I can note that they are trying to harm themselves in my presence and communicate that to the doctor, but determining their likelihood to harm themselves in the future is outside of my scope.

Really? Determining if a patient is at risk for injury is outside the scope of an RN?

 

[Raryn]

I work with two systems. Currently, on our Cerner product, the nursing notes are kept in the flowsheets and you have to actually look for them. They are often useful when the overnight person has no idea what actually happened overnight.

In Epic, the nurses document in the actual notes section. Sometimes this is useful--if there is a baby born overnight that I didn't attend the delivery of, the nurses will put in a note listing all the historical information I need, time of birth, and what the name and PCP are. Sometimes, it's not very useful--when the nurse puts in a note saying she drew a bili, then a second note informing me of the results and that I didn't want to change anything about the plan of care. For the latter, I really wish there was a 'nursing' note, so I could screen these out and read important progress updates from consultants, etc, rather than the hundred nursing care plans.

In EPIC, you can set a filter under the notes section of the chart review tab that goes by "staff type'. I have one set to only show notes from physicians, residents, medical students, NPs, and PAs.

 

[hamstergang]

Really? Determining if a patient is at risk for injury is outside the scope of an RN?

Yes, a suicide risk assessment is outside the scope of practice for an RN. Why do you think psych consults are called in these cases?

 

[RadOncDoc21]

No, as I said, it clouded the issue. She is that hot, that it stops one for a moment. If I could work with her every day, my job would be simpler, happier, and easier. Being easy on the eyes is just a bonus.

Need a pic for verification...just sayin ;-)

 

[20gauge]

As a nurse, do you avoid using "medical terms"? Did your training involve avoiding "medical terms"?

We aren't trained to avoid using "medical terms," per se, but rather to avoid diagnosing conditions. We focus on collecting data for use by the doctor to diagnose the condition (this is a gross oversimplification, but it works for this purpose).

 

[Apollyon]

Need a pic for verification...just sayin ;-)

I think I can find one online. She has lost weight since then.