using names when charting - page 3

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   Retired Nurse
    Yes, chart the names if it is something you may need to remember. CYA
  2. by   DutchgirlRN
    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.
    That's exactly what we are required to do. It's like another member said: If it ever goes to court and there were 5 techs working how would they know which one inserted the foley? Granted routine procedures rarely get hauled into court but hey in a sue happy society why take the chance?
  3. by   chad75
    Well currently I'm an LPN, and if I receive a directive from, report a condition to or consult with an RN I use their name. I.E. Reported to J. Doe RN that patient continues to be in uncontrolled a. fib one hour after administration of po cardizem. She directed me to notify Dr. Heartsalot, Physcian contacted and received orders for a cardizem drip etc. etc.

    As you well know if things go south J. Doe RN might say I never reported the patients condition to her and being an LPN you work under the supervision of an RN according to the LPN scope of practice (I knew before consulting with the RN that we needed to get an order for a cardizem drip, but its all about CYA). This way I have a written record of the time and person I consulted with.
  4. by   Mistorri
    Well, some places insist that you do not use names, while others encourage it. So you need to ask the Supervisor for the policy at your place of employment.
    I know that if there is something that I need to chart like: reported c/o pain to S. Doe, RN, Charge Nurse, I will do so. Especially if that is what I was told to do by a Supervisor. Report it to her and let her handle it. I have seen my name charted on in this fashion many times. You expect it if you are in charge.
  5. by   lovis
    undefined
    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!

    ok, here's a try; im from sweden..and here you have to sign your initials at the end of your statement since you are responsible for writing it down. don't think that'll help you since i'm sure you have different recommendations than us and from state to state as well.
    good luck! /g.
  6. by   Cubby
    Quote from ERslave
    Just remember, this is your chart as well. If you are sitting in front of a judge and jury ten years from now - you need to be able to use that nurses note to recall the days events. If you are charting factual information, it shouldnt matter if you use names.
    My sentiments exactly. If something is reported to me I will chart "Called to unit by LPN Smith..." I will subsequently will chart what my assessment showed, but I see this as protecting the other staff as well. They saw the problem and notified the Supervisor. They did their job, now it's my turn to do mine. I will not chart anyones name if the problem is not a physical problem.
  7. by   djsrn
    Quote from Mistorri
    Well, some places insist that you do not use names, while others encourage it. So you need to ask the Supervisor for the policy at your place of employment.
    I know that if there is something that I need to chart like: reported c/o pain to S. Doe, RN, Charge Nurse, I will do so. Especially if that is what I was told to do by a Supervisor. Report it to her and let her handle it. I have seen my name charted on in this fashion many times. You expect it if you are in charge.
    What if someone charts that they told you something about a patient, but they really didn't. The patient dies,the family sues and they see you were told about what was going on, since it was put in the chart, and it looks like you didn't do anything about it? If you can't tell, one of my biggest fears is being sued!!
  8. by   Fun2, RN, BSN
    I agree with Thunderwolf's who, what, when, where, why, and outcome.

    Full name, or First initial, and last name, then Title for anyone that administers any type of care to your pt, or any important comments by anyone regarding your pt. You never know when/if you will need this information in the future.

    Granted I have only charted on Dr.'s office pt. charts, along with everyone else in the office, so I also always initial under my last statement.


    I guess I will learn what's appropriate for hospitals when the time comes! However, I think it's better to put too much information, than not enough, but keep it short and sweet at the same time. I sure wouldn't want to have to remember details of something by reading vague charting!
    Last edit by Fun2, RN, BSN on Dec 29, '04
  9. by   lovis
    You have a responsibility to write down what the patient has told you, not what your collegues says the patient said...*confusing*. I mean; to be sure you can stand for what you've been told, go to the patient, talk and write. That should keep you on your safe side..and if the patient does agree, you could tell the family. You have to read what's in the charting not what your collegues says that patient said. Second hand info is never the best. thats my recommendation.
    /L.



    Quote from djsrn
    What if someone charts that they told you something about a patient, but they really didn't. The patient dies,the family sues and they see you were told about what was going on, since it was put in the chart, and it looks like you didn't do anything about it? If you can't tell, one of my biggest fears is being sued!!
  10. by   Penny Lane
    Thanks to all for your advice even though it wasn't my question. I really enjoy reading this info and I am glad I joined. I'll be entering nursing 4 in two weeks and myself along with some other students will be asking for some classroom time to really get into correct documentation which I feel we did not receive enough education on that subject. Thanks again!

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