A tricky question. Can you legally document in a chart if you are not on duty?

In my 17 years as an RN, I have been ' on the ward ' and not on duty, for various reasons, and, yes, I've entered detail into notes. Here's my rationale.....

Firstly, in NSW, an RN is a registered nurse 24 hours a day, seven days a week. You're joking I hear? Think of this.... Does your Nursing Registration Cert. state you are only registered between ' business hours ', or for ' night shifts ' only, or even ' whilst on a hospital ward ' ??? No, of course not.

How many times have you stayed back after a shift, either due to excessive workload demand, or your own miscalculation of time management? You have a job to do, in most cases. If you stay back to do your job, then that's good in the eyes of both management and your peers. If you leave early, then you're looking for trouble.

So, it's not extraordinary to be on the ward, after your shift has finished. You think of that extra detail to be documented. Do you leave it, or do it before you go home? If you leave it until next shift, there may be a problem.

( Eg. the INR came back as 12.6 after taking the phone call from pathology services. You were walking out the door, when you suddenly remembered, you didn't hand it over, or document in the patient's notes. If you don't do something, the patient will get another dose of Warfarin, and as a direct result of that particular dose, may suffer a serious CVA. )

So, you're now off duty, but you have something important to record / hand over. What are you going to do ???

I spent several years working in ' mental health '. If I was passing by the Unit, and noticed something noteworthy about a patient, or ex patient, or a safety issue, I would make the effort to either ring the Unit staff on duty, or even go in, and state what I saw, or find the patient's file, and write in the event observed.

Eg. Ex patient observed to be ' drug dealing ' to current patients; current patient in hospital PJs, drinking from bottle of whiskey across the road from Unit ( absconded / inappropriate for Day Leave ??), or two known current patients having sexual contact in public, outside of Unit.

In summary, your actions may make all the difference. How would you feel, if you later found out, that something serious occurred, as a direct result of the information you had, but didn't record / pass it on.....

regards,

Jo,

I often hear people say, but that's against privacy rules....

Is it really? What Act / legislation / Section is being breached?

Think of another concept....

Duty of Care.

Ever been a witness in Court? Ever had a defense barrister grill you about why you did, or did not do something?

Let me say, if you work on that ward, as a member of staff, then you have the right to be on the premises. If you see something, that has a consequence, and you do nothing, regardless if you are 'on duty' or not.... then you will be held accountable for your actions.

If you want to argue 'privacy' issues in Court, when the patient died as a result of some error, then good luck.

Let me tell you about a little story....

Psych unit. Suicidal patient admitted. Nurse receives 'suicide note' from relative, written by patient in his own hand writing. Nurse dismisses importance of note, but does file it with other papers found in patient's belongings. Nurse goes off shift. Thinks about the day's events. Thinks, maybe I should have told the doctor / in charge of shift, about the suicide letter. Nurse 'sleeps' on it. Next day, before nurse is back on duty, patient is missing from room. 1030hrs. phone call from Police. Patient found dead, under bridge. Jumped from top of bridge. Suicide letter, said, " I think I will finish it all, by jumping off the XYZ Bridge one day...".

Case goes to Court. Nurse called as witness. Barrister for 'the family' reduces nurse to tears. Why? Because nurse was deemed to have had vital information, and did not pass it on. Nurse went off duty.... valid excuse? NO! Nurse had Duty of Care to patient, even after going off duty. Reason.... she could of telephoned, or come back to the unit to identify the letter.

In suming up the case, the Judge was highly critical of the nurse. Though not a 'criminal' offense, the patient's death was deemed to have been preventable. The Area Health Service paid a settlement to the family.

Something to think about.....

regards,

GORDO