Hey all!
OK documentation Experts :) This one is for you!
This might be a DUH kind of question...but I am really interested in finding the reasoning. I am looking to adapt my current practices for the safety of my own license if necessary.
I was working with a nurse last night who said that nurses are NEVER to write other names of nurses or managers in our notes (as a general rule, not institutions policy) And most nursing schools teach this.
OK. Fair Enough. But she could not tell me why. (Of course I know you never assign blame in your note to another nurse...IE: Kim left the pulse ox probe on too long which caused excoriation of the L thumb) LOL.
Let me give you some examples of how and WHY I have been occasionally writing names...
Also keep in mind, I work in home care, night shift..we have to write detailed narratives and their are not many people around besides the parents and 5min in the morning with the oncoming nurse to verify or witness that I am doing my job at all
" 1000: Clinical manager Jane Doe here to review equipment and for monthly patient eval."
I would think that one is a good thing because it documents that the office is following up with the patient.
or
"2200: Equipment company notified regarding faulty pulse ox machine, voicemail left with clinical manager Jane Doe, back up machine working without issue, Will Monitor"
The point of this is to document that I followed up and notified the proper people, per policy, for my safety and the patients safety.
or
"0700 Pt stable at end of shift, no change in condition. Report given to J. Doe, RN, patient left in her care at end of shift.
This one just documents who I left the client with at the end of shift..if I just say "homecare nurse" and dont specify who I saw...in theory anyone could have taken over right?