Nursing documentation

  1. hi everyone,

    I'm new here and have a question pertaining to nursing documentation...when you are off the floor and something happens to a patient and the nurse who was still on the floor took care of the situation...i had asked her to do the note she asked me to do it.....so i did and I read it to her after i completed the note....She asked me why i put her name in the note and title....I told her you are suppose to....that if hypothetically if something happens she was the one to help the patient..and by right she should be doing the note....I told her if i just put RN, LPN, Unit Manager that it could mean anyone on the floor or other floor...

    What is the proper procedure to do?...I have always learned to cover your butt when in nursing school yrs ago...Has it all changed? What would someone else do in this instance? and what would the legal ramifications be if you just put RN, LPN...ect.?
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  2. 2 Comments

  3. by   pgrsctrn2be
    IN the past I have always been told and have put the name and title of other nurses or staff members that assessed a pt while I was away from the floor. Never had any problems from this, even been told by a lawyer it was in my best interest to do it this way to CYA!
    Maybe you should check with legal at your facility to make double sure though since each facility has its on policy.
  4. by   Dayray
    It is the best way to CYA. I don't always put peoples names in the chart though. It's up to you really. If you you were ever called into court and you didn't put the nurses name in the chart then you are going to be responsible for what they did. It's up to you but I don't always feel it's right to make someone responsible for helping me out.

    If you leave the floor you are supposed to give a full report and transfer care to the other nurse. So if you are are just running down to pick up lunch and another nurse is "watching your patients" without a full report they are are doing this at their own risk because they have accepted responsibility for your patient without a full report. I am really reluctant to put someones name in my chart while they are in such a vulnerable position and if they were ever called to court I'm sure they wouldn't remember what was done. Now of course if they do something stupid or something I disagree with I put their name in the chart. If I report something of concern to the charge nurse and ask her advise I always document that.

    This is something I have given allot of thought. In L&D when we have a situation requiring fast intervention we all run in to help. Meds are pushed and things are done quickly because they need to be. In that situation I don't put names in the chart because the other nurses are only doing what I would do but we are working together to get things done quickly. I'm willing to take responsibility for the things done that is unless they are done without my knowledge or against my judgment.

    I guess it comes down to this. If you want someone to be responsible for a certain action then put their name in the chart if you don't then don't

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