July 2004, Volume 34 Number 7 , p 23 - 23
© 2004 Lippincott Williams & Wilkins, Inc. Volume 34(7) July 2004 p 23 Bridging the communication gap [LEGAL QUESTIONS: DOCUMENTATION]
BROOKE, PENNY SIMPSON APRN, MS, JD
Having just changed jobs following a move, I'm concerned about this hospital's charting policy. My supervisor has instructed me to just write “Medications given as prescribed” in my nurse's notes instead of specifying the medications. Of course this saves time, but I feel as though I'm skipping something. If a patient were to take a turn for the worse and an adverse drug reaction or interaction were suspected, wouldn't it be harder and take longer to figure out what went wrong if I don't spell out the medications I administer? —L.G., OHIO
You haven't mentioned the medication administration record (MAR). If the patient's drug names appear on his MAR ...