Students not charting...If it isn't charted..who did it?

  1. 0
    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 at.

    We have a person who, since us beginning at that facility, has taken a serious turn for the worse. Now, no one is blaming students or anything like that but where my thought lies is, as a nurse, if you don't chart it--it did not get done, correct? In Florida, I don't know about other states, students are held responsible for their actions, that is why I have NSO coverage.

    So, my question is, if students are not allowed to chart their activities with a patient, and something comes up in the future, what is to protect that student from litigation or worse losing their license?

    I was thinking of proposing something to my school regarding a chart system kept at our school, I just don't know what ramifications that might have.

    We were told that when we get along further in the "program" we will be charting but for now, there is nothing to "CYA."

    I posted this to a staff member who thought this is a good "Group think."

    Anyone have any feedback to assist me in my next move with my school and its, or the LTC facilities policy on students charting?


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  2. 11 Comments...

  3. 1
    Is there another nurse following behind you? When we were first semester students in LTC we did not chart either (except for meds)...BUT- the reasoning behind it was that it didn't really matter. They don't do full physical assessments on residents every day- so what we were doing was "extra" and the nurse is still responsible for the pt. If you notice anything should report it to the resident's nurse-since they are responsible.
    nurz2be likes this.
  4. 2
    Can't the students chart and be countersigned by the mentor?
    danissa and nurz2be like this.
  5. 1
    Since LTC patients were considered stable, we didn't chart either. It had something to do with the way the facility got reimbursed. We reported any abnormals to the nurse responsible for that patient.
    nurz2be likes this.
  6. 2
    We have charted from day 1 of clinicals, and our instructor or nurse co-signs. The only clinical we do not chart in is our psych clinical.
    danissa and nurz2be like this.
  7. 1
    We didn't chart when we did our LTC rotation either, unless we were giving meds. Then we signed with our instructor cosigning. All of our paperwork had to be signed by an RN - whether it was our instructor or the patient's primary nurse because since we were not licenced.

    If I have a student pass meds, I am right there and I co-sign (although when students are with me in the ER, it is strictly observational, so they don't give meds.). But on the floor, it is expected for the student to chart the assessment, a note, sign out meds and have the instructor cosign all of it.

    nurz2be likes this.
  8. 1
    student nurses are not 'legally' responsible. they have no license or permit. students operate under premise that a licensed professional is guiding, assessing, and validating. the clinical instructor is ultimately responsible. if student charting is permitted, the clinical instructor should countersign, otherwise, whatever's being charted isn't valid. this is why i refuse student assignments. yet, i really enjoy working with students - it's a real pleasure. nevertheless, i'm compelled to reject the privilege of working with students for the sake of protecting my license.

    nurz2be likes this.
  9. 1
    Quote from sistermike
    We have charted from day 1 of clinicals, and our instructor or nurse co-signs. The only clinical we do not chart in is our psych clinical.
    Excellent. Must be a good program.
    nurz2be likes this.
  10. 1
    We chart... and sign our name with SPN and our school after it. Then our instructor signs underneath our signature.
    nurz2be likes this.
  11. 1
    Sorry...but I feel the same as the OP. I will chart what I found, did, and everything...and if the facility chooses not to put it as a perm part of the chart fine...but that is a lawsuit in the makes!

    If a facility lets me render ANY care of another human being in their liablity...then they BETTER expect me to document what I did for the record. Not only does that protect them...but me as I don't get some lawsuit or trouble when someone says "oh the student must have done it".

    I would be talking to my college supervisors about it...and sorry, but yes I would make waves to the BON as well...since that can't be their stance on it!!!!!!

    Smart question!!!!!!! And remember...ALWAYS document, and know where to keep those documents (can't take them home...most places can't take them out of you need guidance as to where to keep them for record!!!!). And if they won't let you...honey, you really need to either stand up, or decline that is up to your choice according to situation. The college should stand up for their students...if they aren't...ummmmmm what are you spending money on again????
    nurz2be likes this.

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