June 27, 2018

Notification Documentation | Nursing Hacks # 5


I've had many new nurses write me and mention situations that involved a verbal conversation with a provider. Either the patient deteriorated, or a serious event occurred and there as a problem with the communication trail or lack thereof. I've experienced this before and this is why I document ALL verbal conversations and provider interactions that take place during my shift. Sounds annoying, right? Of course, it does. But understand, when a patient codes or has had sustained issues your entire shift and nothing was done, the finger pointing begins. I love the providers I work with, but I also understand human nature. It's not personal, but if someone is going to get in trouble, they will attempt to deflect and use "gray zones." Gray zones are what I call undocumented conversations. I've had a patient with a sustained heart rate of 140-165 beats per minute for FOUR hours, and a provider tried to tell his medical director, "nursing never notified him." Luckily, I had many timed events regarding the phone calls to his service line (and I documented the operator who paged him each and every time). I worked my butt off to get my nursing license. I won't have my reputation sullied with inaccurate information. Okay, so let's take the previous situation above. My patient has sustained sinus tachycardia at the beginning of my shift. Here is my documentation trail:

Initial Notification
19:30: Cardiology (Dr. Ramon's Office) called regarding sustained heart rate of 140-155 BPM (sinus tachycardia). The patient is asymptomatic. BP 120/45, O2 100% (RA), Pain 0/10, RR 13, T 98.4. Nursing called after-hours service and left a message with the operator (Ruby). Nursing waiting for return call and will continue to monitor.

Second Chance
20:00: Nursing requested unit secretary send second call-out to cardiology (Dr. Ramon's Office) regarding sustained sinus tachycardia, all other VSS. The unit secretary left a second message with after-hours service, spoke to the operator (Ruby). Secretary notified Ruby this was the second request. Nursing waiting for return call and will continue to monitor.

Nursing Escalation
21:00: Charge nurse notified of sustained sinus tachycardia and cardiology (Dr. Ramon's Office) being notified twice. Nursing requested unit secretary send third call-out to cardiology regarding sustained sinus tachycardia, all other VSS. The unit secretary left a third message with after-hours service, spoke to the operator (Ruby). Secretary notified Ruby this was the third request. Nursing waiting for return call and will continue to monitor.

Provider Escalation
22:00: Nursing contacted critical care (face to face conversation - Amy) regarding sustained sinus tachycardia and repeated calls to cardiology (Dr. Ramon's Office). Critical care wants nursing to continue to monitor and wait for cardiology to return call. The patient remains asymptomatic and nursing will continue to monitor.

Condition Update
23:00: Nursing called critical care (phone conversation - Amy) regarding sustained sinus tachycardia condition update, all other VSS. Orders were given for metoprolol and 12-lead EKG. Nursing will continue to monitor.

The point of writing this novel is to show your hard work in you attempting to get this issue resolved. ALL NURSES DO THIS, we just don't document our hard work and follow through. The key is documentation. I could say all day I called and called. Documentation leaves nothing open or "gray." If I'm asked about this a month later, I don't need to guess or infer what my actions were. The documentation is there for all parties to read and track the series of events. Now, this doesn't happen often. But when it does, make sure you take the proper steps in protecting your license and properly presenting your actions step by step. What if this patient has a massive MI and dies? His loved one later sues the hospital, and their lawyer sees these CLEARLY dangerous vital signs for hours and hours? It looks bad. You look bad. Your only saving grace is your notification documentation and escalation steps.