Comment on [deleted]
WhiteOakBayou@lemmy.world 11 months ago
You can’t chart he took it off you don’t see him take it. You have to wait or chart a reason the med was delayed.
Comment on [deleted]
WhiteOakBayou@lemmy.world 11 months ago
You can’t chart he took it off you don’t see him take it. You have to wait or chart a reason the med was delayed.
roguetrick@kbin.social 11 months ago
You can put it in nurses notes, or depending on the EHR put a "note" in the MAR. But you have to actually put it there and then your manager will yell at you. Point is, you need to be sure they actually took a medication you documented you administered at the time you said you administered it.
This stuff isn't "my bosses" though but "standard nursing care."
WhiteOakBayou@lemmy.world 11 months ago
This pt isn’t refusing meds though. I’ve been a nurse a long time, only ER but still, putting in note to the ehr instead of doing one’s job is bad practice. They either take it or refuse. In acute care there’s no “probably took it later” option. People can refuse whatever. I tell my patients (who can leave) this isn’t hospital jail but this guy seems to be talking about dumping a cup of pills and leaving.
roguetrick@kbin.social 11 months ago
We're on the same page.
WhiteOakBayou@lemmy.world 11 months ago
Yeah, this reads like an AITA post and the answer to op is yes lol. I feel like this is 100% not an autonomy issue like op said either. This is hopefully the pt’s home meds or something but what if it was something that needs levels? The 5 rights are for pt safety and right time is one of the easiest to remember. I think your reply explains it best.