I am just curious if anyone else has an employer that says it is okay for anyone to document a nurses note in a resident's chart?? I work in personal care but I know when I worked in skilled nursing the CNAs were not even allowed to look in the charts.
New boss states that anyone including the CNAs, social worker, chaplain etc. should have full access to resident's charts and are allowed to document in the nurses notes. The CNAs don't feel comfortable writing a nurses note and I don't feel comfortable having them do it either. Simply because I am afraid they may chart something that I need to know assuming I will read it and it never gets passed on to me and there is no follow through....you see were I'm going with this.
I think it all depends on where you work.
I am a nursing aide. I am permitted to look in the charts. I am also permitted to write in them if I need to. I don't often need to.
I have to tell the RN anything significant anyway, so they can write that they were informed and their assessment findings and actions all in one place. The vital signs and other paperwork I write on are not in the chart.
I do not have time to be writing extensive notes in charts anyway
Last edit by JDZ344 on May 14, '14