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Saturday, September 10, 2011

Here's what you can chart when you are forced to miss a treatment

Often times we RTs are busy in the emergency room and are forced to be very late or not give a treatment on the floor.  In the old days we used to chart, "RT busy in ER, unable to give treatment."

However, a lawyer for the hospital informed us such charting will never hold up in court.  He said there is no excuse for late treatments.  So, this forced us RTs to do some creative lying, and so we now chart, "Treatment Refused."

My coworker has come up with a more creative thing to chart when this occurs:

"RT in ER/  Patient was in no respiratory distress per RN."

He added, "I know this because if the patient was in any sort of distress, or even if the patient was producing annoying lung sounds, the nurse would have called."

How are you guys told to chart at your hospital?


Anonymous said...

saying tx refused would actually be a LIE and if the patients family or the patient was upset enough could result in you getting canned for falsifying documents- most places have cameras these days.

I write.
"Miss due to critical pt on another floor".

I think i will add the phrase "pt not in distress" as your explanation is plausible.

Rick Frea said...

Our lawyer said that charting anything along the lines of "unable to do tx due to...." makes the hospital look incompetent. He said if we're that busy we should call in help. Although by the time help got here the tx would be late anyway, and you cannot predict when the ER is going to be busy. He also added that the "opinion of the RT that 90% of the treatments are not needed anyway will also not hold up in court." Darn lawyers.

Anonymous said...

Our template says "triaged per hospital policy."

Unknown said...

We use a classification system and if they're a class 3 or below (ambulatory, no surgery, no lung dx) we can omit due to classification protocol. We don't use it often and we reclassify pts q 72 hrs. It gives us something that's repeatable and tested.