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Mum's the word

I work in a busy outpatient radiology clinic that's just instituted an electronic medical records system. One of the radiologists doesn't want us to document any patient complaints related to the radiation therapy he performed, such as patient discomfort experienced during the procedure. (In the past, the nurses documented all patient-care-related complaints in the handwritten nurses notes.)

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As nurses, aren't we responsible for documenting all aspects of patient assessment and care? And shouldn't we also document passing this information along to the patient's attending physician?-A.D., MD.


You're right to object to this physician's directive. Documentation of patient care is a very serious nursing responsibility regardless of format, and the physician shouldn't try to limit information that needs to be shared with other team members. If you omit important information and a patient is harmed, you'd appear negligent in your nursing care as well as your documentation.


An electronic medical record system should let nurses document all patient-care-related information, such as assessment findings. It should also let you document what and when you communicate to physicians, as well as follow-up care, changes in treatment, and other interventions that result. If the system you're using doesn't have this capacity, take action to improve it.


You don't say why this radiologist objects to documenting certain information. Possibly he needs more training on the new computer system, or he may have legitimate concerns that should be addressed. As always, use your facility's chain of command, starting with your immediate supervisor, to get to the bottom of this conflict, clear up misunderstandings, and fine-tune your new documentation process.



Common practice isn't always best practice

At the facility where I work, patients must give informed consent for transfusion of whole blood and other red-blood-cell-containing components, plasma components, cryoprecipitate components, and platelet components. The consent process informs them of the risks associated with these products, which are issued by the facility's blood bank. My question involves blood product derivatives such as albumin, intravenous immunoglobulin (IVIG), and hemin for injection, which are dispensed by the pharmacy. Even though these derivatives carry the same risks as blood products, our consent policy doesn't require informing patients of these risks and obtaining specific consent.


The director of pharmacy believes we should require the same kind of consent for all blood products and derivatives, but our quality improvement manager disagrees. She says not requiring informed consent is common practice in the large healthcare system we belong to.


I want to follow best practice, not common practice. Can anyone give me insight into why informed consent wouldn't be appropriate for blood derivatives?-P.S., COLO.


Our legal consultant agrees that common practice isn't always best practice, and this is a good example. She's surprised that your facility's quality improvement manager doesn't support a consent policy based on a firm foundation of reasonable care and behavior. As you say, the risks to the patient are the same for all blood products, and the fact that they're obtained from different departments is a poor reason not to inform him about those risks.


Informed consent is intended to protect both the patient and the facility, and our consultant can't think of any reason a facility wouldn't want this protection. Take this concern to the next level, following the chain of command. For example, you may need to ask your manager to request a review of this issue by the facility's legal counsel. Following your facility's chain of command ensures that you're not out of step with its policies and procedures.



Pump or no pump?

I care for a patient with a percutaneous endoscopic jejunostomy (PEJ) tube in her home. When administering feedings, I give them via an enteral feeding pump. But when she was recently hospitalized, she told me she received a bolus feeding into the PEJ tube. Now I'm wondering, is using a pump really necessary?-K.L., NEV.


Our consultant says that although an enteral feeding pump isn't essential, you should never give a bolus feeding via PEJ tube. Unlike the stomach, the jejunum can't handle a large amount of food at once. Feedings should be dripped in slowly or continuously-either via gravity drip or a pump-to mimic the way the jejunum normally receives food from the stomach and duodenum. Overloading the jejunum with nutrients may spark dumping syndrome, so your patient was fortunate if she experienced no adverse reactions to the bolus feeding.



Caught in the middle

My nurse manager and another staff nurse have filed separate event reports about the same medication error and named me as a witness. Both included things in their reports that I didn't hear or see.


The other night my manager called me at home about this and said something that sounded like a threat to my job. When I tried to talk with her about it the next day, she said I must have misunderstood her.


Now I'm worried that I may lose this job, which I need. How do I get myself out of this mess?-L.A., MICH.


Normally we'd advise you to go up the chain of command, but in this case your manager is part of the problem, not the solution. Schedule an appointment with the director of human resources and explain the circumstances to her. She can tell you the best way to handle this in your facility.