Charting un-witnessed behavior

[Pkirk618]

One night I was charge nurse. The nurse on the other side of our two winged facility charted that she had an issue with a patient and charted appropriately. Next day, the powers that be find out that there's a history with the kid (escalates often) that when he acted up with my colleague on the other side, her charting wasn't suffice. But based off what she told me, it was good.

I knew something relatively small happened and it was charted. Maybe even an incident report was completed. But that nurse handled thing pretty spot on.

But because they are seemingly trying to CYA for stuff happening before our shift and nitpicking at the things that did happen to our shift, they asked me to chart on something I didn't see. And I didn't see it---and I don't think its right that that ask me to compromise myself/license for the sake of CYA. I get I'm supposed to ensure all charting gets done but I do this based on the information I get from other nurses. If something new arrives to someones attention, those nurse managers should use their time to track that nurse to make the charting more accurate. I can't chase nurses down that work different shifts anyway.

What would you do? Is this even remotely right? What nurse practice acts in Illinois protect me? Sorry, pressed for time and I need advice. You guys got the condensed version but the bottom line, I wasn't there for anything they might be worried about so I never saw this patient.

Thanks.

[BlueDevil,DNP, DNP, RN]

"Patient reports..."

[Meriwhen, ASN, BSN, MSN, RN]

Don't we chart what CNAs report to us all the time? Isn't that why we call them our "eyes"? For example, I might chart "CNA reports resident combative with HS care" or "CNA reports resident refused shower x3". Since the aides can't write nurses notes, it's your duty to chart what they report to you. Of course, you also need to document what you, the nurse, did with that information.

Exactly: we don't chart what we see, but that it's what the CNA, patient or other staff reported...and we make it clear that it was a report to us from someone else.

OP: that would be the best that I could offer them--I'd chart based on what the CNA/staff told me but that it would be clearly stated as being a second-hand report. I wouldn't risk my license by falsifying documentation just so they can CTA. Because should something happen with Joint or the BON because of it, the hospital certainly wouldn't cover mine.

[Pkirk618]

no it was another RN who charted what she saw. Because they couldn't, or wouldn't chase that RN down for some "needed" additional specifics about the situation, they wanted me to fill in the blanks.

So, this hardly compares to having eyes in the form of a CNA seeing something and reporting to me but I understand how that could work under other conditions.

Bottom line, one RN charts what she see's and our supervisors want me to chart things that may or may not have happened to meet certain standards (perhaps there was a restraint method used, I don't know but you get the point). This, I'm not comfortable doing and I'm sure it's against some nurse practice act based on that merit. I just wanted some additional feedback. Thanks!

[NicuGal, MSN, RN]

Be very careful how you word it. Use quotes and names and make sure you chart if you told someone,etc. We had a case at work where the charge nurse on another floor charted what the aide did, but the way it was worded and the fact that she didn't report to a doc, etc was what brought this case to suit. Don't just use CNA, make sure you put a name to the person who reported it to you.

But, you can't chart on presumptions....that will get you in hot water. Tell her no and that is it.

[chevyv, BSN, RN]

I wouldn't chart on it because I didn't see it. Does the supervior know you did not witness the incident? Stand firm!!

[Elladora]

I think what you are describing and what others are answering are two entirely different situations. On a normal day to day shift, charting as others have mentioned "patient reports" or charting what the CNA reported to you is valid. However it sounds to me like you are being asked to more or less make up charting to fit a situation. I absolutely would NOT do that. The original RN needs to fix her charting if the facility is unhappy with it, not you.

[jadelpn, LPN, EMT-B]

no it was another RN who charted what she saw. Because they couldn't, or wouldn't chase that RN down for some "needed" additional specifics about the situation, they wanted me to fill in the blanks.

So, this hardly compares to having eyes in the form of a CNA seeing something and reporting to me but I understand how that could work under other conditions.

Bottom line, one RN charts what she see's and our supervisors want me to chart things that may or may not have happened to meet certain standards (perhaps there was a restraint method used, I don't know but you get the point). This, I'm not comfortable doing and I'm sure it's against some nurse practice act based on that merit. I just wanted some additional feedback. Thanks!

If you are charting what may not have happend, then in fact you would be making stuff up, which is pretty well unethical and illegal in most every forum. And in the event of a lawsuit, you would not be able to say with certainty that the items that you charted happend at all. Which makes you look unethical, and I am sure that if it came to that, your supervisors certainly would not say "welll we told her to chart stuff". If your DON wants the stuff charted, then in fact she can do it--as she has just as much "knowledge" as you do on the matter--as you both were not there.

IF RN said to you "Patient x was acting out. Per MD order, a theraputic hold was instituted for x amount of time, with good results, and current assessment is WNL" then the only thing that you could chart was" RN Y stated that .......and this RN evaluated outcome....." and only if in your practice you assess patients after they may or may not be restrained.

Bottom line, I would tell the supervisors that in your professional opinion, this RN acted to the standard of the policy in the care and treatment of this patient as it was reported to you at the time of the incident, and that you would be happy to chart that, otherwise, it is unethical to chart otherwise.