Source:

Nursing2015

October 2007, Volume 37 Number 10 , p 24 - 24 [FREE]

Author

  • Penny Simpson Brooke APRN, MS, JD

Abstract

 

The members of our code team make quick, rough notes during a code to document medications, procedures, patient responses, and so on. Sometimes we even write on the bed sheet--anything to get accurate information down in a hurry. Yesterday, after one of the nurses finished charting after a code, she shredded the reminder notes to protect patient privacy. Now administration is threatening to fire her, saying she destroyed legal documents. The facility's policy and procedure manual says only that charting must be legible and accurate. Can you help clarify this issue? - d.n., miss.

 

Nurses frequently take rough notes that they later transcribe in the patient's medical record, but these aren't an official part of the medical record.

 
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Health care facilities should have policies and procedures for staff to follow during a code. Typically, one team member is assigned to document the events using a flow sheet provided by the facility. Flow sheets are designed for quick, accurate documentation of the interventions provided to the patient.

 

Does your facility have a procedure for documentation during a code? If it does and the nurse assigned to document didn't follow it, she might be subject to disciplinary action.

 

If your facility provides a flow sheet for codes but it isn't user-friendly, work with other members of the code team to design a better one.