using names when charting

BittyBabyGrower, MSN, RN · Dec 18, 2004

If we do a task for someone else, we have to chart ourselves. Our legal is of the mind that anyone could write any other person's name in the chart. The only exception is in the case of an emergency.

BittyBabyGrower, MSN, RN · Dec 18, 2004

If we do a task for someone else, we have to chart ourselves. Our legal is of the mind that anyone could write any other person's name in the chart. The only exception is in the case of an emergency.

mrdoc2005 · Dec 18, 2004

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.

mrdoc2005 · Dec 18, 2004

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.

Thunderwolf, MSN, RN · Dec 18, 2004

The chart is a legal document. Documentation is objective...who, what, when, where, who, and outcome. Nothing subjective. Names and credentials are included.

Thunderwolf, MSN, RN · Dec 18, 2004

The chart is a legal document. Documentation is objective...who, what, when, where, who, and outcome. Nothing subjective. Names and credentials are included.

jsn43210 · Dec 18, 2004

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

Burnt Out, ASN, RN · Dec 18, 2004

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.

jsn43210 · Dec 19, 2004

It is amazing to me how much variation there is in charting practices....

djsrn · Dec 19, 2004

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.

jaimealmostRN · Dec 19, 2004

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."

jaimealmostRN · Dec 19, 2004

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).