using names when charting - page 2

Hi, Quick question; when you all chart, do you put a name to a person? Example: Bob, nursing assistant, placed foley. Or do you just chart nursing assistant placed foley? I was taught not to... Read More

  1. by   mrdoc2005
    You must put the last name to make it legal in the courts. I do put names on things that I think are important. Ex. I would put I.V. started by J. Doe RN.
  2. by   Thunderwolf
    The chart is a legal document. Documentation is objective...who, what, when, where, who, and outcome. Nothing subjective. Names and credentials are included.
  3. by   jsn43210
    Quote from djsrn
    One of you responded you chart the person's name cuz if there are 5 nursing assistants on duty how would they differentiate who they were talking about in court" I just don't see putting a person's name down and making it easier to get someone in trouble. Just like when you have a med error. you don't put it in the patient's chart, you make out an incident report.Does this make sense to anyone?
    That is ludacris. As a doctor, if I left my name out because I didn't want to get in trouble.... Why should nursing be any different?

    As for the original question, do they really neglect to teach charting in nursing school?

    Jason
    Last edit by VickyRN on Dec 18, '04 : Reason: Private website edited out of post
  4. by   ?burntout
    Quote from ?burntout
    If someone placed a foley for me (if I am tied up in an emergency or whatever), I chart the person's first name, last name and credentials. Or sometimes I will use the first initial of their first name along with their last name.
    I do ask the person that performed a procedure (like a foley, IV, NG tube insertion) to chart what they did to my patient themselves-some do and some don't: I, however, will chart on another nurses' patient if I do something for them. If another RN, LPN or NA witnesses a patient fall, and I didn't witness it myself because I was talking with a doc or in another patient's room, I also include their name in the chart and the incident report-but I never chart that an incident report was filed in the nursing notes-that is a no-no.
  5. by   jsn43210
    It is amazing to me how much variation there is in charting practices....
  6. by   djsrn
    To the person that asked if nursing assistants can place foleys; they can where I work with the proper training.
    To Jason, this is a chat room, I am posting things to discuss, that's what chat rooms are for. do they really teach doctors to be rude in med school?
    Thanks to everyone else that gave thoughtful, insightful replies. After reading the "whys" to charting people's names, it makes more sense to me.
  7. by   jaimealmostRN
    As an extern, I ALWAYS put the dr.'s name if we had to page her/him in an emergency or ugent situation.... "0300 page to dr. jones. pt complained of substernal chest pain 10/10 stabbing, O2 applied, no change in pain level."
  8. by   jaimealmostRN
    oops forgot to add, if someone places an IV or some sort of interviention on someone else's pt, then they chart it, not the primary nurse. But yes, in our school we are always taught to use names as it is a legal document and never to use subjectives. I personally use tons of quotes, pt stated, "I can't breathe" and clutched chest. I know some will disagree with this, but if you really feel funny about using names in the progress notes (or where ever everyone reads/charts) chart these interventions in the flow sheet...everyone has access to it, but most don't read it b/c it's usually for nursing notes. I'm not saying this is best but it's perfectly legal to chart here (b/c it's in the chart).
  9. by   winterblue
    Recently attended a legal nursing seminar. Was taught to always use names. Also, it is appropriate to use personal pronouns in charting when describing your own actions, I didn't know that before.

    BTW, the stories told in that seminar were a bit scary! Physicians who had tried to go back days later and make a late entry; proven after the note was analyzed by a handwriting specialist.
  10. by   SmilingBluEyes
    Yes, I do use names where appropriate. I think, legally, it is a must.
  11. by   nurseyd
    I recently worked in a facility where we did "team" nursing, and the concept was really taken too far- people would chart anything as though they did it even if the procedure was done by someone else.... so in that situation if I was writing a note on a pt I would document IV started by D. Smith, RN, etc. etc. hoping that by example they would realize you need to be responsible for your practice even though we were a team.
    Last edit by nurseyd on Dec 22, '04
  12. by   been there
    Quote from djsrn
    Hi,
    Quick question; when you all chart, do you put a name to a person?
    Example: Bob, nursing assistant, placed foley. Or do you just chart nursing assistant placed foley?
    I was taught not to chart the actual person's name in the chart. Also, does anyone know of any professional websites on legal issues related to charting? thanks in advance!
    For your legal protection it's always safest to put the name and title of the person who actually performed a technique on your patient on your chart documentation. Be direct, clear,and never vague, in charting. If a nursing assistant placed a foley is there documentation in his personnel file that he is qualified to do this? I wasn't aware that CNAs could do more than basic cath care. Maybe in your state? And now there is controversy about CNAs allowed to pass med? God help us and the patients.
  13. by   graysonret
    I've always used the name of the person in my charting. I want no confusion in the future, in case a question is raised...especially since I am an agency nurse.

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