I was at a staff meeting today where it a discussion came out regarding our documentation of IV insertion. We have a PICC team doing PICC's, drsg changes, and are also called for difficult IV starts. I am one of the few who always tries to document the insertion on the computerized charting myself. Several of the nurses will tell the floor staff where they started it, and expect that they can do the charting. I was at an AVA convention 2 years ago where the speaker was adamant that the inserting RN should be the one to document the IV start. I brought up the concerns that if there are adverse outcomes related to the IV, that it would be important we had accurate documentation. Some nurses felt it would be the nurses actually infusing after the IV was placed who would be responsible- I mentioned nerve damage from the actual placement as an example. I also mentioned that the floor nurses may not know our names and may chart "PICC RN" which doesn't leave our name on the legal record. Am I right to be concerned or am I being too picky here?

 

Thanks so much!

You are definitely ***not***

You are definitely ***not*** being too picky. The nurse performing the specific procedure must be the one to accurately document what she/he has done. This is and has been a major issue in legal cases. Continue your fight to get this practice changed for someone else to be responsible for documenting what another nurse has done. 

 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861