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Should an RNs clinical notes contain exact dosage/frequency/date if that info is captured elsewhere in the agency's computer system?

Monday January 27, 2014
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Dear Nancy,

I am an intake RN in a home health agency. I receive various orders from physicians regarding medications such as Coumadin. My documentation includes writing the orders in our computer system under the order tab, then writing a clinical note under the clinical tab stating, for example: “Relayed Coumadin orders to patient. He verbalized understanding and repeated the correct dosing/frequency. VM to Susie Nurse to repeat Protime/INR in 1 week.”

Is what I have written in the example above sufficient in the clinical note, or does my note have to include the exact dosage and date the order must be repeated? The difference is time consuming since I have already written the orders under the order tab.

Some in our office believe it is critical to write the actual dosing/frequency in the clinical note. From a survey or legally could our agency or the RN be dinged by survey or have trouble in court if those words/exact dosing, frequency is not re-written in the clinical notes?

Josie

Josie

Dear Nancy replies:

Dear Josie,

The response to your specific question is best answered by seeking advice from your agency's legal counsel or, if that is not possible, from a nurse attorney or attorney who not only knows nursing practice but also the requirements and accreditation mandates in your state for home health agencies. Some general comments can be made here, however.

There is no doubt the second version of the documentation is more complete and specific. If this is seen as more desirable, indeed even required, you might want to consider developing some kind of checklist documentation that allows for the information to be placed in the clinical note. It obviously would need to be adapted throughout the agency and provide for documentation of required information in the situation, such as the date, who was informed of what and signature requirements.

You would not need to necessarily reinvent the wheel in this regard. There is a wealth of information online about developed home health care forms that may or may not be able to be adopted to your agency and state requirements. Likewise, there are textbooks on home healthcare and forms that you also could review.

If you do find one or ones that might be helpful to you and your agency, get them reviewed by legal counsel or a nurse attorney or other attorney in your state. Also, have them adopted by whatever forms committee/clinical committees you have within the agency.

Regards,
Nancy




Nancy J. Brent, RN, MS, JD, is an attorney in private practice in Wilmette, Ill. This information is for educational purposes only and is not intended as legal or any other advice. The reader is encouraged to seek the advice of an attorney or other professional when an opinion is needed.