Charting things done by others...

Nurses General Nursing

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On my floor we chart what WE do. We would never blindly chart anything. I floated to a new floor and the informed me that I would be charting ADLs and IO's based on flow sheets handed to me by the CNAs. I informed them that I would not be charting those things as I only chart what I do....

They were very upset and argued with me but I did not budge,,,,

I have had issues in the past with CNAs making up vitals and guesstimating I&O....

Am I in the wrong here? This seems like a no brainer....

Specializes in ICU.

Guys, this is really not a big deal! " am care done" will not put your license at risk or throw your whole day off". " temp 101.2, Tylenol given" doesn't hurt either. Just because you didn't take the temp doesn't make it illegal or painstaking to write it.

If an RT gives a Neb tx to a patient with SOB, your really not going to chart " ned txt given by RT with improvement in SOb"

Big deal. It's a part of the job. So etimes we chart what others do and others chart what we do. It's ok.

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I contend that it is a big deal....what if I have a patient on strict I/O with CHF and the aid hands me a list of guestimated I/Os? This is the age of the 5 star resort.....if I chart am care done then the patient tells the vp rounding to every room that they did not get their bath....who will take the heat? The person that charted am care done, that's who. Give me a reason why each of us cannot just chart what we do including the aids? Where I work they are trained in how to chart. There really is no excuse.

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No excuse especially when the aids are missing for half the day and sitting in front of the computer shoe shopping for the other half.....

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No excuse especially when the aids are missing for half the day and sitting in front of the computer shoe shopping for the other half.....

This is the real issue.

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Specializes in ICU.

Nice generalizations. I guess the as answer is fire all the aides and do it yourself. They are obviously of no use to you.

You seem to be way more concerned of charting something wrong than if something wrong was actually done. I hope of you are that concerned and can't trust your aides you don't let them touch your patients, do it all yourself, and then there is no question of documenting something that you didn't do.

When I works ICU, if there was an aide I didn't trust, I did it myself and there was no question on the documentation.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I contend that it is a big deal....what if I have a patient on strict I/O with CHF and the aid hands me a list of guestimated I/Os? This is the age of the 5 star resort.....if I chart am care done then the patient tells the vp rounding to every room that they did not get their bath....who will take the heat? The person that charted am care done, that's who. Give me a reason why each of us cannot just chart what we do including the aids? Where I work they are trained in how to chart. There really is no excuse.
If they are trained to document then they should be doing their job.....facilities I have worked the CNA does not document
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Specializes in Gerontology RN-BC and FNP MSN student.

Where I work I have to sign and hand in their (CNA) worksheets, shower sheets, and the I and Os are entered by me. It is policy that the nurses acknowledge their work. Also to review the information to see what needs attention ( such as weight loss/gain, skin issues, adequate I & O ). They know nurses can not be everywhere and DO everything, but if there is something that was not addressed it will come back to the nurse in charge of those patient during that shift.

I try to roll with the punches ( when being pulled) :nurse: and do the best I can with out getting bent outtaa wack. It can always be something if you let it get to ya.

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Specializes in Gerontology RN-BC and FNP MSN student.

Also how could you not know if their not taking care of what they say their doing? You are assigned to these patients. You would know if their not getting care or who is doing what....I would assume. Then if you know the care is being done right, you can easily document it? (per so and so) If its not being done....well you need to address that issue. Hope this helps...:cautious:

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You supervise your aides, if they're not doing their job, that's kinda your problem. If you don't trust them to record their observations correctly, make the observations yourself. Otherwise, "CNA reported X input and X output," should be sufficient.

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Specializes in Family Nurse Practitioner.

I once had a CNA charting urine counts for a patient who was not putting out any output and was bladder scanned and found to be retaining a large amount of urine.

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We use Epic and we can actually chart "performed by" if we didn't do the vitals etc...

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