Students not charting...If it isn't charted..who did it? - page 2
I am a student in FL. I have been thinking about something recently and was curious if you could help me come to a conclusion. We, as students, are not allowed to "chart" in patient medical records, at the LTC facility we are... Read More
- 1Apr 14, '08 by DeLanaHarvickWannabe, BSN, RNQuote from ms kyleethat's what we did also, kylee. i signed "university of delaware student nurse" after every note i wrote, and "udsn" on the mars and flow sheets. also, some of our instructors weren't big on us writing notes, but for my first hospital rotation, i wrote several notes. i don't remember writing notes in every rotation, but i do know i charted on mars and flowsheet (except for psych, community health, and older adult assessment).we chart... and sign our name with spn and our school after it. then our instructor signs underneath our signature.
as for whether it's "necessary," i don't think that matters! nurses who are able to write effective notes will benefit in the long run, and how can we learn to write notes if we don't start immediately? i know that in ltc, maybe there aren't full assessments written in the progress record on a daily basis, but how often are any kind of notes written? are there progression of care, or just note writing by exception? and in other settings, such as the floor, even if the student nurse's note brings nothing new to the medical record, who cares? i've always charted after the students because of time issues (they left before my shift ended, and had less patients, that kind of thing) and i don't care if my assessment on the flowsheet is identical, i want evidence of my assessment charted. if there is a note written and i feel as if i do not need to add anything, i will still write something so that a nurse has written a progress note that day.
that was much much longer than i intended.
long winded as usual,
- 0Apr 14, '08 by nurz2beI appreciate all of your comments so far. I am in FL, and the state nurse practice acts DO say that students are responsible for delivering the same care as the nurse who is in charge of that patient, sort of an oxymoron saying students care is = RN care.
We had a legal class last week and it was clearly stated that "students do not "ride" on anyones license." Yes the instructor is "responsible" to a point but the instructors license will not come under fire, in most instances, if something goes wrong. (This is the information presented to us by our instructor and a lawyer who specializes in appearing in front of the FBON). If I, a student, "harm" someone it falls under the facility, the school, and ultimately myself. We were told this is why "most" schools either insist upon or highly recommend nursing students to get malpractice insurance. As I personally have sought out doing through NSO.
Anyway, I am really seeing the reality of not having anything charted. Yes, when there are issues we write a "note" for the nurse in charge of that patient. If it is something of great concern we always go to our instructor.
As far as is anyone coming behind us except for our instructor and the nurse only passing meds, we don't see a soul the whole time we are there. We do dressing changes, Foley's if need be, meal assistance, bathing assistance, turning, and whatever else that patient needs for the time we are there, except for meds.
Call me paranoid but I do not want anything to jeopardize my future as a nurse, nor do I want anyone else to have to answer for something that our school does not deem a "priorty." I mean seriously, we have nearly 12 nursing instructors and no one has had an ah hah moment. I am glad nothing "serious" has gone wrong but just because it hasn't does not mean that it won't, right??