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Although I've been an OR nurse for years, I've just started work at a new hospital. At the hospital where I worked before, we could document on intraoperative records the reason for any delay in surgery. Here, I've been told to document if a delay occurs-but not to document the reason because the surgeons raise a fuss if we note their lateness as the reason for delay. Are we running any legal risks by omitting this information?-T.B., OHIO
Every facility has its own policies and procedures for documentation. You'll need to comply with your new employer's way of documenting or you could risk losing your job.
Comprehensive, accurate documentation can refresh your memory about the circumstances of an adverse event if a legal issue arises, even years later. However, only information relevant to the patient's care belongs in her medical record-for example, if surgery was delayed because her venous access was inadequate. Most ORs keep logs on the surgeons' scheduled arrival times and document trends, so that information is available elsewhere.
If you observe a pattern of delays that you believe places patients at risk, file an incident report with your risk manager so she can investigate the situation. In this way, you're giving your employer necessary information while following facility protocols.
We had a confusing situation recently in the ED where I work. Police brought in a man who'd been injured while caught in the act of committing a rape. He needed blood work in order to get appropriate medical care, and the police wanted a blood sample for evidence. The man refused to have blood work because he didn't want to incriminate himself. The staff felt torn between respecting the patient's right to refuse treatment and wanting to help the police (and ultimately the victim of this crime). What was our legal duty?-W.S., N.Y.
You should have very clear guidelines on how to proceed in this type of sensitive situation. You can't force treatment on a patient without his consent, and you can't cooperate with the police if they ask you to do something illegal.
The police can seek an emergency court order to get a blood sample if a patient refuses, and you can provide care without consent in an emergency if the patient's life is at risk. But you shouldn't have to decide these issues without administrative support. Maybe your ED needs to hold a staff-development session to clarify the guidelines in such situations.
Your responsibility is to give the patient fair, competent treatment, regardless of what anyone suspects about him-not to help the police solve crimes. Speak with your facility's risk manager before you find yourself in this situation again.
I work in an outpatient clinic. Recently a patient confided to me and to her primary care provider that she has a drinking problem, but she asked that we not record what she said so her insurance company won't find out. She's afraid she'll lose her job if the information leaks out. Can we legally keep this information "word of mouth" only?-T.E., N.H.
No. Alcohol is a drug, so you have a responsibility to investigate and objectively document how your patient uses it. Record her responses to the CAGE questionnaire and document what she tells you about her drinking habits; for example, that she drinks six 12-ounce glasses of beer each day.
Your patient's admission may have been a cry for help. Do your best to help her find the resources she needs to overcome her problem before it further damages her health or threatens her job. And document your interventions.
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