Charting things done by others...

Nurses General Nursing

Published

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....

Up Vote Up Vote ×
Specializes in ED.

This is fairly common in my department (ED). I just put out in the comments "per whoever".

Up Vote Up Vote ×

While your post gave me food for thought, looking back on my LTC stints, I don't see why CNA's would have been given worksheets to fill out if I had been responsible for literally doing every task stated. However, I knew which CNA's were truthful and which I had to go behind and check over myself. Imagine a foley bag overflowing onto the floor at shift change.

Up Vote Up Vote ×

I frequently chart things that were done that I didn't necessarily do. I'm not charting that I did them, just that they were done and at what time. I work in the ED and so I usually am aware of what's going on with my patients' care, and it may be different on the floor, where you didn't actually observe the CNA's activities, so you don't know for sure that it was done other than the CNA telling you it was. In that instance, if you're not sure something was done or done correctly, you could double check first. Go into the patient's room and see if their Foley has been emptied and their water pitcher refilled, ask them if they got their bath, etc. Sure, it takes time to do this, but I think it's important to be on top of what's going on with your patients anyway. I would want to know these things were being done and being done properly, even I wasn't the one charting on it. That's just good patient care.

Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Just document am care per report to this nurse per so and so.

Up Vote Up Vote ×

Why aren't the aides doing their own charting?

Up Vote Up Vote ×
Specializes in ICU.

Don't CNA's take vitals for a reason? If you don't trust them, then you need to do them yourself. If you really don't trust them, your not doing any service to your patients by just not charting them. If you are administering meds off of their vitals ( and holding them). Then you must trust them......

Hey, do it all on your own if you want. But no one is asking you to do anything illegal. Charting a vital sign by someone else isn't saying you took it. Just like charting a lab value you didn't draw or spin your blood and get personally yourself. Would you not get orders from a doc on a potassium of 3.0 if it wasn't you who personally drew the blood or even spun it in the lab?

Think about it ...... As long as your are not saying you took the vitals and they are wrong, you are fine.

Up Vote Up Vote ×
Specializes in Pedi.
Why aren't the aides doing their own charting?

This is my question... why can't the CNAs enter their own ADLs and I&O? It was expected that they do so when I worked in the hospital.

Up Vote Up Vote ×
Specializes in Emergency.

Only chart what you do...this sounds terrible...If the CNA's do the work and record why can't they chart? Ridiculous...some b.s. cost-cutting measure no doubt. I only chart what I do...occasionaly a nurse I am working with (I am a PCT) will say "here are the vitals I took at such and such a time...." I always say-"Ok then you can put them in..." It is absurd that they cannot spend the literaly 20 seconds to chart a set of v/s-especially when they are already in there doing charting! Lazy! I only chart what I do-This is medical work 101 as far as I am concerned. I also must disagree with one of the above posters who says they just add an addendum...per so and so etc...not safe!

Up Vote Up Vote ×
This is my question... why can't the CNAs enter their own ADLs and I&O? It was expected that they do so when I worked in the hospital.

In one of the hospitals I've had clinicals at, the aides were not given computer access

Up Vote Up Vote ×
Specializes in Pedi.
In one of the hospitals I've had clinicals at, the aides were not given computer access

Well that's stupid. If I had to chart everything the aides do, I'd rather just have no aides and do everything myself. I'm a nurse, not a secretary.

Up Vote Up Vote ×
Specializes in Cardiac, ER.

I agree with the others,.my first question is why aren't they charting their own work? That said, I work ED and I frequently chart others work,.ie 18 g L AC per Davis RN, wound cleaned et dressed per HG PTCA, etc.

Up Vote Up Vote ×
+ Add a Comment