Documenting for another nurse?

[Barnstormin' PMHNP]

Feel free to correct me if I am wrong on this. A friend of mine works at a snf that wants the RN's to document on the LPN's patients, even though they do not work on that unit and don't even see those residents during the shift. I told her that that is a really bad idea, I personally think it's a legal nightmare waiting to happen. What's worse is that her DON is on board with it.

[Barnstormin' PMHNP]

The charting that the LPN's are asking them to do is not the supervisor type of thing like falls, ER admits, or when a patient needs a secod set of eyes on them for an assesment (they already do that as their Supe position). From what I understand there are about ten to twenty patients/residents on "charting" on each unit. That means they may be on abx, had a fall recently, new admits, behavior etc. The charting is done at the end of the shift, basically the snapshot of the shift or more if something came up. The LPN' know their residents on their 40 bed unit. The RN supervisor does NOT. They do not usually have any kind of contact with the residents on the other units because they have their own that they work plus the other units have an RN as well. The issue is when they are the Supe and the LPN's are alone on the unit and want the Supe to chart for the LPN's shift so they don't have to. Which brings me back to my question. How can a nurse be legally expected to chart on a resident that she doesn't even see? If they are unit Supe does that imply they have had report and therefore the RN is technically responsible? They do not get report on anything on the other units other than incidents and patients who are unstable from the outgoing Supe. I know I personally would not agree to chart on people I have not assesed and observed over the course of a shift. The LPN's are telling the RN's what has happened for the shift and expect the RN' to document off of their obsevations. Can you just imagine the problems that can arise?

[CaringGerinurse525]

That's a whole different scenario then an RN being a supervisor and expected to chart on her assessments. I would never ask the RN to chart on something I was responsible for charting. I also would decline if another LPN was behind and asked me to do her charting. The only time it is acceptable is if I happened to witness a situation that the resident's nurse did not.

I would tell your friend to check her facilities protocols and guidelines for charting. It should clearly state what the RN is responsible for charting during the shift. It sounds to me like the other nurses are being lazy.

[xoemmylouox, ASN, RN]

I wouldn't chart for another nurse. If I was your friend I'd start looking elsewhere as I can only see this ending badly.

[MunoRN, RN]

I don't really see the problem, there's really nothing that can't be charted on by anyone so long as it is properly explained: "Per Jane Doe LPN's report, patient ...."

[xoemmylouox, ASN, RN]

I don't really see the problem there's really nothing that can't be charted on by anyone so long as it is properly explained: "Per Jane Doe LPN's report, patient ...."[/quote']

I doubt this is what the facility is looking for.

[Caribbean Character]

Sorry, if I didn't see or do it, I won't chart it. You would be putting your license on the line.

[MomaNurse]

Well then. This isn't an RN - LPN thing at all. This is a shove a 40 person pass at the floor nurse and have the sup document so we can save the cost of a second nurse on the unit! Your friend should offer to do some treatments, cover the desk or run interference with families/patients/staff to free up the LPNs time. That way Patty Pumpkin LPN can do her own notes!

BTW tell your friend never to document on the Medicare patients if she's never seen them. I'm sure that's what this employer is getting at.

[MomaNurse]

I'm betting your facility is engaging in unecessary and redundant documentation policy. Whoever makes the policy there ought to check with the BON on this. LPNs can complete their own documentation.

I've worked in skilled nursing for nearly four years now, and I've never once had to have a RN document anything for me.

Don't misunderstand. It's not charting FOR you, it's COSIGNING assessments. I'm not talking about shift notes or Meds and treatments.

[CapeCodMermaid, RN]

I've been in long term care for longer than some of you have been alive. I never co-signed anyone else's documentation, nor was I ever asked to. LPNs are licensed people responsible for their own practice. If someone asks me to assess a resident's status, I document what I assessed. As a DNS,I would never expect any nurse to document something she hadn't done or seen herself. I would consider that to be falsification of a medical record and grounds for termination.

[MunoRN, RN]

We chart all the time on things we didn't assess ourselves, and there's absolutely nothing wrong with that. I just recently charted that a patient was found to have empyema on CT, I didn't assess that nor did I interpret the CT, I referred to someone else's assessment which is completely fine so long as you clarify who's assessment that was if it's not assumed. I also chart what was found on a heart cath and what was done when I float to cath lab, even though I didn't find anything or do anything. Scribes to nothing but chart and did actually do a single thing they are charting. So long as you are qualifying anything you chart with who actually assessed what you are charting there is absolutely nothing wrong with it.

[youngheartoldhead]

1. If you are asked to chart for someone else don't do it. But if you are unable to refuse, include the name of the person you are charting for. Then sign your name. The signing of any document for anyone is strongly frowned on.
   

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