I was called into the office of one of the nurse-managers on L&D recently, regarding some documentation I had made during a labor/birth.
What I had written in the nursing documentation was "EFM strip reviewed by Dr. So-And-So." Sounds like no big deal, right? Well, apparently this doc complained to another doc in her group, who went to our chair of OB. The chair didn't see a problem with my documenting with Dr So-And-So's name on the record, because she was covering the pitocin for another doctor (different practice), who was in the office.
Here's where it gets sticky.
Some of the practices will cover for other practices, if the woman's physician is not in-house or "immediately available" for pitocin or epidural coverage. Usually, we (nurses) don't even document this on the patient record, because it's a courtesy thing. (I don't agree with this "covering" of pit and epidurals - if it's YOUR patient, get YOUR ass in and cover your own patients!).
However, when something is going wrong - decels on a strip - maternal BP in the crapper, causing fetal distress, etc - we routinely document the physician who is reviewing the strip, and any interventions done.
Dr So-And-So's colleague feels that we should only chart "attending aware of EFM strip" or something along those lines - and not actually document the physician's name on the record.
HOLD UP! You want me to what?!?
Apparently the physician colleague went on to say that if it was every subpoenaed for court, he would refuse to hand over the list of attending physicians on duty during that time period.
Great. Just freaking great.
Meanwhile, if I (as the nurse) do not chart accurately, I could be flamed on the stand about my poor documentation. Not to mention, how many nurses will recall specific details, years down the road in court?
I told my nurse-manager, in no specific terms, that I will continue to document as I do, to cover MY ass. I'm not out to harm anyone - patients, women, babies, physicians, midwives, fellow nurses, etc - but so help me, I will document completely and thoroughly for not only accuracy in the chart, but for best recall for myself if I am ever taken to court.
Simply put - if I don't chart it, it didn't happen.
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I'm an RN in New Zealand (not L&D - they don't use nurses for that here, just midwives), but I agree 100%. You document everything and cover you! That's exactly what we have learnt and it makes sense, too bad if the Dr doesn't like it.. that tends to suggest they were doing something not quite right.
Holy Crap.
Stunned to think they actually think that you should be vague.
That is just scary! SCARY SCARY SCARY!
But isn't that what it's all about???
OB's, man... They are probably the most "all about me" group of people I have ever heard of.
These kinds of stories are one more reason I don't use surgeon's for my obstetrical care.
Good for you for standing up for yourself. :) Now if only other women knew how to do the same, maybe our c/s rate wouldn't be on the way to 40%.
This is absolutely ridiculous! What about the rights of the patient if said doctor actually does something wrong? Good for you for standing up for us!
I can sort of understand the concern of the doctor - they are just doing a favor.
But, uh, if decisions about care are to be based on that simple little efm reading, then yeah - your name needs to be on it. Because you are the one there making a decision, and if something goes wrong that is traced back to that decision, that reading - you need to be responsible and be held accountable.
Bravo for standing up and doing things correctly.
Wow, they straight out told you to lie in your documentation. Just...wow.
I won't say that social workers are NEVER intentionally vague to cover their own asses. I've had some questionable advice from superiors, but I've never been straight out told to lie because someone complained about their name being in a note where it damned well belonged.
I really respect you for standing up to the bullshit. The doctors are NOT your bosses, however much they might fantasize that they are. You are a professional in your own right. If the docs are concerned about other docs covering for them and screwing up, they need to just work it out for themselves.
"Apparently the physician colleague went on to say that if it was every subpoenaed for court, he would refuse to hand over the list of attending physicians on duty during that time period."
I'm sure he talks a good fight, but I'll believe it when his ass is sitting in jail on contempt of court charges.
Good for you!
--A Future Ob/Gyn
Well you have been linked to a med mal lawyer (eric turkowitz, Google him) website as an example about how this behavior happens all the time. Something to be proud of.
I'm a midwife in New Zealand as well and I couldn't agree more with what everyone else has said. The minute you make a mistake, the docs will crucify you - cover your a.. at all times, although I have to say that it is so sad that things have got to this and that we can't work harmoniously with each other any more.
You have every right to document who reviewed the chart.
"I don't agree with this "covering" of pit and epidurals - if it's YOUR patient, get YOUR ass in and cover your own patients!)."
Do you work 24/7/365 cervix? Everybody (even doctor's) need time off. I think you would be singing a different tune if you actually walked a mile in an ob/gyn's shoes. It is easy to pontificate about what someone "should" do when they actually haven't done the job.
To the last anonymous re: coverage of pit and epidurals:
Maybe I should have clarified something: it's not a solo practitioner who is on call 24/7/365 - his is a physician on call for his/her practice of multiple physicians, who have, at the most, a 24 hr call period to cover.
It's called "not putting the patients first" over their home life when on call. Sorry - if you're on call, and have a patient or patients on the unit, then get in and assess them and cover your own pit and epidurals!
All I can say is unbelievable. And people wonder why nurses have a high level of stress.
Great job standing your ground. One word of advise, Watch your back and cc your union on this issue because you are on someones radar now. If they go after you it wont be for what you did but for some trivial policy issue that will be played off a totally unrelated to your advocacy.
What do your fellow nurses think about this issue? At my hospital there is an in - house doc on call 24 /7 to cover emergencies and we don't put their names on the chart unless the primary doc is on vacation or something and they are taking over care of the patient.
The legal specter of the retrospectoscope goes on for 20 years in my state (2 years statute of limitations only begins to run when the child reaches majority).
So the problem is, how many charts do I want to get my name on? For a patient with whom I have no prior relationship with, and will have only a breif clinical encounter and not have a hand in, or option to alter the outcome after my courtesy assesment. And you know in reality the OB cannot come do their own assessments because they would never get their clinic work finished; and we know how understanding a waiting room full of patients can be when delayed a few hours.
The solution lies in adequate house staffing by a doc who's paid and insured to do just this kind of thing; see patients he's never seen before and manage their labor. Easily a million dollar proposition for the hospital to buy 24/7 coverage plus liability insurance; but I assume the nursing staff would push for it.
I agree with the others... but I'd go one step beyond. From now on, not only would I document it, but I'd also ask another RN to witness it... so that if the doc tries to deny it, you've got two of you to back up the statement.
I don't care what anyone says, I'd document it exactly the way you have. If you simply say it was reviewed by the attending, they'll hang you out to dry. In nursing, we are always taught to be specific and careful.
Had a similar problem the other night... OB chewed me out for not checking a fingerstick on a PP patient with GD. He asked why and I said, "Because you didn't order it. You only ordered one for the morning." He yelled, "Then you didn't read my order correctly!" So we looked at it together and it said, "A.M. CBC and BS by fingerstick"... he then backpedals, apologizing and saying, "Oh sorry. I guess I didn't finish the order"... then adds "every 4 hours" to the end of the order! It made it look like he had said that all along... and that I was negligent in not carrying it out. So against his wishes, I added in "Added by M.D. at..." He was MAD.
I don't care... my license... I worked hard for it... I'll protect it!
Schpedoinkle! That's BANANAS!!! He doesn't want you to name names? In a patient's chart? Is he crazed?
He should stop doing favors for his doctor buddies.
That's bullshit.
Some "anonymous" went and threw a tantrum on Eric Turkewitz's blog for linking here. Sadly, it's exactly this kind of patient-second behavior by doctors that leads to malpractice lawsuit and butt-covering when a doctor really does something wrong.
Good on you for standing up and doing the right thing.
Well mythago that's rich since I am the same anon who stated:
"You have every right to document who reviewed the chart." above.
Do you always prejudge people you have never met? Let me guess you are not an RN or an MD. I have no problems with RN's documenting whatever they feel is necessay in the chart. They are there watching the patient at the bedside. I often am not. The "issue" is when a trolling lawyer gives this as an example of:
"Ever wonder how malpractice gets covered up or why it doesn't appear in the medical records? Well, an anonymous obstetrical nurse from Pennsylvania opened that little door for us today."
Eric offers no support for this statement (besides this link). Yet his crony's state this "happens alot of the time" (again without any unbiased support). You have a right to your opinion (as does eric), but is really rather meaningless unless you have evidence to back it up.
anonymous, are you a lawyer? Because if you're going to play the "if you're not in the profession STFU" game, you yourself have no business telling Eric what he has or hasn't seen in two decades of malpractice litigation.
It also doesn't help your argument when you go and misstate what Eric said on his blog. Throwing a hissy fit about Teh Evil Lawyarz is not an argument.
It can be worse. See Sides v. Duke University, 74 N.C. App. 331, 328 S.E.2d 818 (1985) (plaintiff nurse fired for refusing to commit perjury to cover doctor in malpractice suit).
Wow....a lot of bad energy here!!
I work as an OB hospitalist in an inner city hospital and we have a very similar problem. The private docs have all hired midwives and most of the time the doctors aren't in the hospital anymore. The problem is that in order to run Pitocin or get an epidural the protocol says that the doctor needs to be there, not just the midwives. So the midwives ask us if we will cover for Pitocin or an epidural, but we aren't really covering the patient, we are only covering for an emergency that might happen, and we are covering for those anyhow. That's part of the reason why we were hired in the first place - that and to cover clinic patients and patients who just walk in to the hosptial without having had any prenatal care.
If the nurses put our name down on all those charts where we are just "covering" for an epidural, we'd be on thousands of charts a year...so we either have to be the bad guys and say we won't cover, or take the risk of getting sued when we aren't even really taking care of the patient. (The midwive and the private doctor are doing that. If you are really covering a patient for another doctor, the other doctor talks to you about the patient and you meet the patient and take over the care.)
There is a fine line here.
When doctors get named in two suits in a short period of time the State Board starts to send them letters. It doesn't matter what the circumstances were. If your name is on a chart and there is a bad outcome, you are going to get named first and dropped from the suit later.
I think the answer might be to tell the private doctors that the nurses keep putting our names on these charts so we won't cover and let the private doctors and the hospital and the nursing staff figure out some solution. I really like the fact that we are seeing more midwives. They do a great job and provide a lot more support for patients in labor than most doctors. But if doctors have to be in the hospital even when a midwife is there, many practices aren't going to think its much of an advantage to keep them.
And I'd be really ticked too if a nurse wrote down that I had looked at a monitor strip when it was another doctor's patient, just because I happened to be looking at the tracing on the computer at the time. How would she like it if I documented that she was looking at a bad tracing and got her involved in a lawsuit, when she wasn't the nurse taking care of the patient.
Please mythago do tell how placing what eric stated in quotes (ie. verbatim) is misstating what he wrote?
It's exactly like what Nurseline said....you shouldn't be writing the house doctors name on private charts when they are just covering for emergencies. They aren't really taking over care of the patient and you are making it sound like they are on the chart. Tell me...did the doctor you are complaining about meet the patient and write a note on the chart that he/she was taking over the care?? Was there a midwife in house for the practice? What's the other side of the story here?? It sounds like you are holding yourself up to be some great protector of medical care for women. You got problems lady.
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