How long can a nurse wait to document?

Documentation is communication between you and any other provider who reviews your documentation.   So, if the documentation is not in place you are not communicating.  Standard practice is to document as soon as you finish the task you were performing.  Realistically, shifts are super busy to the point that the first time a nurse is able to document is when the shift is over and another nurse has assumed care of that nurse's patients.  If that is the case, the best you can do is to document then.

The exception to waiting till the end of the shift to document is the Medication Administration Record (MAR).  Documentation of medication administration occurs immediately AFTER the medication is given. There is no waiting and also you do NOT document before administering the medication.  Actually, all documentation is to be done after the task is completed and never before.  I like to say "There is no Fixing-To documentation."  

Some nurses have the mistaken belief that they can leave the hospital and then document when they come back for their next shift and that is untrue and a habit that if caught will result in disciplinary action by the Texas Board of Nursing/BON.  Think about what documentation is used for; it is used to communicate to others when you are not present to tell them in person. So, if you are gone and the documentation is missing then no communication is happening and patient care is impacted.

The best practice is to do the task then document.   You are also likely to remember more important facts if you document timely. So, not only is it nursing standard, best for patient care, but is also more likely to protect you and give  you documentation you can rely upon in case something comes up later.

Closing eyes while at work - DANGER, DANGER

You are tired, or sick, or just resting our eyes so you close your eyes for a short time period at work.  Of course right then is when another staff member, or management or a family member comes by and sees you "sleeping."  You are most likely about to be terminated and reported to the BON for sleeping.  You think I will explain that I just had my eyes closed for a short time period, but that explanation does not make the termination cease or the BON stop from taking disciplinary action.  The assumption always is if your eyes are closed, you are sleeping. So be very careful!!

A nurse passed on what she encountered when she started a new night job:   she was told by nurses who had been working at the facility for a while that if it was slow at work they would take turns watching each other's patients and take turns sleeping.  They assured her it was acceptable.  She said she thought it sounded off, but she wanted to check with an attorney that represented nurses.  I told her that it was not EVER acceptable and also she may want to reconsider working in a place like this where nurses thought it was acceptable behavior to be paid for sleeping on the job and ignoring their patients.

Timing for Giving Medications including Narcotics

 Nurses have said there is a  policy that you have an hour leeway to give medications. So, if a medication is ordered at 9 am you can give it as early as 8am and as late as 10 am.  First there is no national policy  supporting this practice. Second, you need to see with your own eyes that such a policy is in place where you work otherwise you are not protected by following this belief.  Do not rely on what others tell you.  Some hospitals do have policies that give 30 min to 1 hour either side of the selected time of administration.. You just need to be sure the hospital/clinic/prison/LTC etc  where you work has that policy.

If the medication in question is a narcotic you can end up being charged with giving a controlled substance outside the timing set by the prescribing physician.  If a physician orders a narcotic every 4 hours and you give it one hour early or even 30 minutes early, the Board of Nursing/BONs are saying you have failed to follow the physician order and gave a narcotic outside what was ordered by the physician's order.  When it comes to narcotics nurses need to wait until the stated time has occurred before giving the medication so that you are never too early and can avoid that complaint with the BON..

The same applies to scheduled medications that are tine specific.  You need to know what your facility's policies are and what the requirements are for that specific medication ( an example are antibiotics) and give the medication appropriately.  If the medication is strictly scheduled there is no time leeway.  

Texas Board of Nursing (TX BON) moves

 Moving day is finally here and the Texas Board of Nursing/ BON has moved to a new location.  Hopefully the new offices are nicer although I have heard they are still too small.  Here is the new address:  

                                   Texas Board of Nursing    
                  1801 Congress Avenue, Suite 10-200    
                  Austin, Texas    
                  78701  

Surrendering A Nursing License

 You have received notice you are under investigation by the BON and they offer to resolve the investigation by allowing you to surrender your license.  Maybe you no longer practice in that state or maybe you have not worked in awhile or you are just burned out and not sure if you want to return to work.  Surrendering a license may seem like a quick and easy resolution for a stressful process, but you MUST do research and think about the broad ramifications of surrendering your license.  Surrendering a nursing license could result in you being placed on an EXCLUSION list which means you cannot work for any employer in any capacity that accepts Medicare/Medicaid or Federal funds.

So, maybe you are thinking of quitting work as a nurse and returning to work as an aide so that you can continue to do patient care. If you surrender your nursing license and are placed on either the federal or state Office of the Inspector General's exclusion list you would not be able to work as an aide because the LTC facility accepts Medicaid/Medicare.  Remember the exclusion is for any employer and any position.

The exclusion list can have other impacts other than just working in different positions in healthcare. The exclusion has also impacted a nurse who wanted to obtain a reverse mortgage which is funded by Federal monies--no monies if on the list.  Surrendering a license can also keep you from obtaining another professional license.  A nurse applied for a real estate license and was denied because of a surrendered nursing license.

Think carefully before surrendering your license and do your research.

Texas Board of Nursing Agreed Orders-a Recent Problem

I am not sure why this year I have seen a huge increase is nurses contacting me soon after they have signed an Agreed Order with the Texas BON wanting the Order changed or removed.  Most of these nurses were not represented by an attorney, but there were also a few who were represented by an attorney who did not regularly represent nurses before the Board.  It is important to realize that an Agreed Order is a settlement agreement or contract between the Board and the nurse.  Like other agreements/contracts in life, the time to negotiate and question the Order is prior to signing.  It is very difficult to obtain a change in an Order and if that request occurs soon after signing, the likelihood of success is decreased immensely.

 Some of the nurses explained the reason they signed was the pressure the investigator was placing on them to sign.  Once again, an attorney can help with this by inserting themselves into the communication with the Board and freeing the nurse up to work and not having to stress over the Board.  A good lawyer will keep you informed of what is happening and also provides you with copies of all documents from and to the Board.  The attorney should also obtain approval for all agreements with the Board.

TPAPN Board Orders are now Confidential

As of September 1, 2013, TPAPN Board Orders are now confidential.  This is a vast improvement since the statute was changed a few sessions ago requiring the Board to be involved anytime there was a practice issue associated with a substance abuse/addiction issue.  This corrects situations where nurses had sensitive personal information available online for all to see.  Nurses who were referred to TPAPN by the Board and had a mental health  diagnosis or who had an evaluation detailing sensitive personal information had limited choices when they were referred to the Board.  It appears there will be further changes or polishing of the TPAPN process in the near future, so be sure to watch for information and remember it may be in your best interests to consult with an attorney who knows the Board and TPAPN.

To Clarify:  only new TPAPN Board Orders are confidential; the Board is not going back and changing previous Board TPAPN Orders from public to non-public orders.  Since the TPAPN orders are confidential they are not reported to the databank/NURSYS.