Nurse overdocumentation

[rokshana]

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"?

yes.

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[20gauge]

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

Definitely not in my scope. I can initiate interventions to reduce the risk for injury while in hospital, but I can't determine if they are likely to harm themselves after discharge.

There's very little nurses can do without an order from the doctor or a medical directive.

 

[Psai]

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).

We have our own set of nursing diagnoses. We don't use them in real life (I have yet to hear a nurse provide a nursing diagnosis in real life - they're hilarious!), but it helps to understand the difference between the roles of doctors and nurses. If my patient starts coughing, develops shortness of breath with crackles in the lungs and lower leg edema, the nursing diagnosis associated with these symptoms is "Fluid Volume Excess." If I identify a patient with "Fluid Volume Excess", I communicate these findings to the doctor and perform interventions to reduce the symptoms - raise the HOB to reduce the work of breathing, administer scheduled diuretics, monitor fluid intake, educate the patient on fluid restrictions, etc. The one thing I don't do is diagnose CHF. That's outside of my scope.

My mistake, you're totally right. I meant to say medical diagnostic terms, not medical terms which nurses use daily of course.

 

[hamstergang]

Meh.

We had a case of a trauma patient a few years back that psych cleared, and he promptly committed suicide less than an hour after being discharged.

While obviously everyone involved was taken aback and had a hard time, the ICU nurses had all felt pretty strongly that he shouldn't be discharged.

I don't think charting it is the best way to go, but none of us are perfect, and nurses tend to get to know their patients pretty well. Their concerns shouldn't be dismissed or ignored (or worse, berated, as in this thread)

I'm not sure I get your point. That we don't always get it right doesn't mean it's not in our scope of practice. In this very thread, you have a psychiatrist and a nurse, among others, stating that a suicide risk assessment is not within the scope of practice of an RN but is within the scope of practice of psychiatrists. That should pretty much settle the issue were addressing, right?

I don't see anyone berating the nurse's opinion, only how it was presented. If a nurse thinks a patient is a risk then they can convey that to me and let me take that into account when I make my risk assessment.

 

[dpmd]

Meh.

We had a case of a trauma patient a few years back that psych cleared, and he promptly committed suicide less than an hour after being discharged.

While obviously everyone involved was taken aback and had a hard time, the ICU nurses had all felt pretty strongly that he shouldn't be discharged.

I don't think charting it is the best way to go, but none of us are perfect, and nurses tend to get to know their patients pretty well. Their concerns shouldn't be dismissed or ignored (or worse, berated, as in this thread)

The issue is not the nurse being concerned or sharing their gut feeling with the docs. The issue is contradicting the doctors in the notes in a way not consistent with their scope of practice. If the nurse had instead documented something like "patient tearful and expressing concern they may harm themselves if discharged (or whatever specific behavior or statement from the patient rubbed them the wrong way), Dr So and so notified" there would be no reason for controversy. Instead it is more like the nurse documented "ER doctor and surgeon agree patient safe for discharge but this writer strongly disagrees and feels there is high likelihood their diverticulitis will perforate if discharged"

 

[Old ICU RN]

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.

 

[Old ICU RN]

As with everything, presentation matters. The RNs assessment may have been spot on, how she choose to document it ( and didn't follow up with the provider with her concerns) make that chart look like a pissing contest between providers and staff.

It also helps when MDs and RNs understand and accept that our licenses are independent from each other. I can't use the defense: well that's what the doctor ordered if it's a mistake and the patient is harmed. Usually if I catch an error like that, I contact the provider, explain what I'm seeing and why I think it's questionable. If it's a goof, my charting usually simply states something like as " Clarification of Med order X sought with Dr Jones. Updated order received to hold X and start Med Z. Read back and verified. Time and date." And that's the end of it.

That being said, I've always approached my relationships with MDs as we are both working for the patient's benefit. I like to work with my providers. As a 20 + year veteran of a high acuity ICU, when I reach out in the middle of the night it's never with the intent to see whose sleep I can mess up, it's to update and to bring the provider to the bedside through me so they have a clear picture of changes that could evolve into a dangerous situation. I want to save you work and frustration ( and myself as well) by nipping problems in the bud. Thankfully we have a lot of standing orders available now that RNs can use to create a detailed clinical picture when we call. I hated the old days where I HAD to call for lab orders and then call back with the results. By the time a good ICU RN is reaching out they will now have the information you need to form a true clinical picture even if you aren't physically at the bed side and our charting should reflect the objective data we present; labs, change in respiratory patterns, increased O2 requirements, current/stat ABG, and if needed a CXR that you can pull up at home if your system has that kind of access etc...

I want to be able to answer your questions objectively and provide clear data, not vague opinions such as " she don't look right" Yes, I acknowledge that we do have a few "brilliant " souls that share my title, but don't have a clue how to present a case over the phone in such a way as you feel like you are almost at the bedside through our report. But I've had a few MDs reduce a newer RN to tears by not talking with them to sort out the story when they weren't being as articulate as MD wanted. I've even had a few tell the new RN, "Is Chris there tonight? Good, put him on the phone. Chris? What the hell is going on?" And it's not even my patient. Guess that comes from being the old kid on the block.

But please understand that some of our ( idiotic) charting occurs because we bound by policys that leave little room for critical thinking like us being required to call every critical lab even though that lab makes sense in the current setting. Example lab calls me with an elevated cre level on a dialysis patient, takes my name and records it in the chart, but doesn't give me leeway to say, they blew off 2 days of HD, I'm starting CRRT and this baseline lab is to be expected. If I don't document that I called the doc with that "critical " lab I can be hauled over the coals even though the lab was the same as it was in the ED and that is why they came to the unit to start CRRT

I guess what I'm trying to say is we need to have an open dialogue so we each know what is required by the hospital. And as far as those effing nursing care plans; they are dinosaurs required by JACHO and we hate them as much as you do. They are a huge time suck that pulls me away from actually providing care. If you have any ideas on how to put that beast down, please share.

 

[mvenus929]

And as far as those effing nursing care plans; they are dinosaurs required by JACHO and we hate them as much as you do. They are a huge time suck that pulls me away from actually providing care. If you have any ideas on how to put that beast down, please share.

I hear a lot of hospitals are moving away from accreditation by the Joint Commission. We are moving towards ISO-DNV. Not sure how that affects the care plans

 

[Psai]

I hear a lot of hospitals are moving away from accreditation by the Joint Commission. We are moving towards ISO-DNV. Not sure how that affects the care plans

Good. I never understood why people paid so much money to a useless organization and then act like they're a boogeyman that must be feared. WE PAY THEM

 

[Precedexed Out]

As with everything, presentation matters. The RNs assessment may have been spot on, how she choose to document it ( and didn't follow up with the provider with her concerns) make that chart look like a pissing contest between providers and staff.

It also helps when MDs and RNs understand and accept that our licenses are independent from each other. I can't use the defense: well that's what the doctor ordered if it's a mistake and the patient is harmed. Usually if I catch an error like that, I contact the provider, explain what I'm seeing and why I think it's questionable. If it's a goof, my charting usually simply states something like as " Clarification of Med order X sought with Dr Jones. Updated order received to hold X and start Med Z. Read back and verified. Time and date." And that's the end of it.

That being said, I've always approached my relationships with MDs as we are both working for the patient's benefit. I like to work with my providers. As a 20 + year veteran of a high acuity ICU, when I reach out in the middle of the night it's never with the intent to see whose sleep I can mess up, it's to update and to bring the provider to the bedside through me so they have a clear picture of changes that could evolve into a dangerous situation. I want to save you work and frustration ( and myself as well) by nipping problems in the bud. Thankfully we have a lot of standing orders available now that RNs can use to create a detailed clinical picture when we call. I hated the old days where I HAD to call for lab orders and then call back with the results. By the time a good ICU RN is reaching out they will now have the information you need to form a true clinical picture even if you aren't physically at the bed side and our charting should reflect the objective data we present; labs, change in respiratory patterns, increased O2 requirements, current/stat ABG, and if needed a CXR that you can pull up at home if your system has that kind of access etc...

I want to be able to answer your questions objectively and provide clear data, not vague opinions such as " she don't look right" Yes, I acknowledge that we do have a few "brilliant " souls that share my title, but don't have a clue how to present a case over the phone in such a way as you feel like you are almost at the bedside through our report. But I've had a few MDs reduce a newer RN to tears by not talking with them to sort out the story when they weren't being as articulate as MD wanted. I've even had a few tell the new RN, "Is Chris there tonight? Good, put him on the phone. Chris? What the hell is going on?" And it's not even my patient. Guess that comes from being the old kid on the block.

But please understand that some of our ( idiotic) charting occurs because we bound by policys that leave little room for critical thinking like us being required to call every critical lab even though that lab makes sense in the current setting. Example lab calls me with an elevated cre level on a dialysis patient, takes my name and records it in the chart, but doesn't give me leeway to say, they blew off 2 days of HD, I'm starting CRRT and this baseline lab is to be expected. If I don't document that I called the doc with that "critical " lab I can be hauled over the coals even though the lab was the same as it was in the ED and that is why they came to the unit to start CRRT

I guess what I'm trying to say is we need to have an open dialogue so we each know what is required by the hospital. And as far as those effing nursing care plans; they are dinosaurs required by JACHO and we hate them as much as you do. They are a huge time suck that pulls me away from actually providing care. If you have any ideas on how to put that beast down, please share.

JACHO, another "non-profit" that makes big bank. I hope these type of ignorant organizations start losing power. Not every damn thing needs a "non-profit" accrediting body.

 

[Raryn]

Sometimes I love nursing documentation though. From my hospitalist shift last night, for a patient they woke me up at 3am for:

"Gave 1 tablet of Norco at 0222. Rt leg pain score 10/10. Patient stated norco was not effective. Also stated unable to sleep due to pain. Text paged hospitalist for sleeping pill and morphine order. Received order. Went to assess pt. Pt is sleeping."

 

[Precedexed Out]

Sometimes I love nursing documentation though. From my hospitalist shift last night, for a patient they woke me up at 3am for:

"Gave 1 tablet of Norco at 0222. Rt leg pain score 10/10. Patient stated norco was not effective. Also stated unable to sleep due to pain. Text paged hospitalist for sleeping pill and morphine order. Received order. Went to assess pt. Pt is sleeping."

The classic 10/10 pain while smiling, laughing, or playing games on the cell phone.

 

[TraumaLlamaMD]

Sometimes I love nursing documentation though. From my hospitalist shift last night, for a patient they woke me up at 3am for:

"Gave 1 tablet of Norco at 0222. Rt leg pain score 10/10. Patient stated norco was not effective. Also stated unable to sleep due to pain. Text paged hospitalist for sleeping pill and morphine order. Received order. Went to assess pt. Pt is sleeping."

“Woke patient to administer morphine. Pt now states pain is 11/10 and requests Dilaudid.”