DITTO!   why you are doing what you are doing and the resident's response to what was done are the missing pieces to most legal puzzles whether survey, quality of care investigation or litigation.  Please just remember "BECAUSE"...For example, , I called the physician BECAUSE ______________; The doctor ordered(or did not order) ____________ BECAUSE ______________, The resident did or did not respond BECAUSE_____________________. 
-----Original Message-----
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]On Behalf Of Michelle Witges
Sent: Tuesday, February 17, 2004 9:54 AM
To: [EMAIL PROTECTED]
Subject: Re: Physician Notification Guidelines

Amen to that.  I have been trying to educate the nurses to that fact but so far it has not happened.
----- Original Message -----
Sent: Monday, February 16, 2004 11:07 PM
Subject: Re: Physician Notification Guidelines

I agree, however, the abbreviation was not the point I was trying to make.  Nurses should document why the physician was called and what the physician recommended.

Documenting that there is a new order [NO] is useless, we can all go to the order sheet and see the order, we need to know why the order was written.  More important why an order was not written after notifying a physician of a resident's condition.

Delores

I brought this up  at one of the facilities and they said they were told they could use the NO abbreviation.  I looked at their approved abbreviations and sure enough it is on the list.  I feel that it increases a propensity for error.

 


Susan

 





Delores L. Galias, RN, RHIT

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