I work 12hr shifts in pediatric home health on a case that I split with another nurse. Even from back when I was an EMT eons ago, a tech, research tech and now a nurse I was always taught that my notes should be "stand alone" documentation. If another staffer makes a footnote on a chart or document, I should not "reuse" their note as I'm not the one who initialed and dated the footnote but instead I should make my own footnote in my own words. If another staffer documents a finding such as a rash or wound I might refer to it as "3x4cm area of erythema noted on anterior right thigh above knee, originally noted on 1/1/01 by previous shift...". But I should NOT write "erythema in right thigh as described in 1/1/01 nursing note, especially since hopefully the site doesn't look exactly the same as it did a day or two previous. Plus I am not the one who made the previous observation.
It was a major issue in research if you used someone else's footnote. (I did some work with QA/QC and I know the rules of FDA clinical research are similar to nursing standards but in some areas research is more strict.)
The reason I ask is the other nurse constantly "reuses" my footnotes even if they are not exactly relevant to her shift (such as if I reference a particular day's scheduling issues (extra appointments) that were a one time issue). The patient had some minor skin breakdown and a petechia like rash. Rather than document her own findings (and the area had to be improving since it was nearly resolved by the third day when I returned) she just referenced "rash on leg as noted in notes from 1/1/01".
I measure the area and fully describe my findings (share, color, any open skin, drainage) plus any actions or interventions (called doc, called supervising RN, etc)
So am I making myself more work by describing what I find and only referencing the original discovery (area of erythema as originally noted on 1/1/01)? Or am I documenting properly? I am not too worried about the other nurse unless she tries to change my documentation again (she decided to change my footnote without initialing and dating in the chart, the nurse case manager took care of that issue), as that is an issue for the office to discover and correct. I just want to make sure what I am doing is correct.