Charting for physician

Editorial Team / Admin · Aug 29, 2005

Hello,
I am new at this site, but I have been searching on a topic you may be able to help me with. I work in a busy pediatric office with three physicians. We are required to follow the doctor from room to room and do his/her charting for him/her during the exam. Sometimes they tell us what to write, other times we are left guessing. I wasn't taught anything about this in nursing school and have never heard of anyone else having to do this. I am not even sure if this is within my scope of practice as I can't find anything else about it. I am getting paid a fraction of what a physician is, yet I am doing everything for them. Does anyone else have to do this I am becoming very frustrated.

Most definitely WAAAAAY out of the scope of nursing practice.

fab4fan · Aug 29, 2005

1. You're a nurse, not the physician's personal secretary. You do not take dictation.

2. Check with your BON; this may jeopardize your license.

(Just when you think the "handmaiden" image has died...)

suzanne4, RN · Aug 29, 2005

There is no reason that you should be doing this. They can dictate into a machine and have a medical transcriptionist write it up for them. And there is nothing that will cover you for doing this................

I highly recommend that you put a stop to this as soon as possible.

**canoehead, BSN, RN** · Aug 29, 2005

I think that probably it's not license threatening as long as you are very clear that these are not your findings, and you get the doc to sign every note. But the mind boggles at what a bunch of babies these docs are. Tell them to dictate it into a tape recorder so you can type at the desk and take calls for the office, thus being more productive. (or hire a dam secretary and a maid)

nursen06 · Sep 8, 2005

Definately out of your scope. I would never chart for a physician. Don't put your license or rep on the line.

moon30 · Sep 9, 2005

Hello,
I am new at this site, but I have been searching on a topic you may be able to help me with. I work in a busy pediatric office with three physicians. We are required to follow the doctor from room to room and do his/her charting for him/her during the exam. Sometimes they tell us what to write, other times we are left guessing. I wasn't taught anything about this in nursing school and have never heard of anyone else having to do this. I am not even sure if this is within my scope of practice as I can't find anything else about it. I am getting paid a fraction of what a physician is, yet I am doing everything for them. Does anyone else have to do this I am becoming very frustrated.

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Hello:

I am not a nurse yet only a student,but I do know charting for a doc is a big NO! I have been in the hospital and seen a number of doctors for my sickness and never saw a nurse chart for a doc.

Look at this from a patient point of view__What happens if one of the patients request their records for another physician to look over their case. The new physician will look at the physician notes that you wrote and think that is from the doctor. What if he calls the doctor and have a question about something that you over look by being a nurse. The patient decides to sue the doctor for poor charting and overlooking something important. Who license will be on the line? The doc will probably keep his and you lose yours.

Nursing school is too hard to play with the license. How do you know that your license is covering this?

Remember your license is your bread and butter. Look for a new job because once you rep is gone it is gone!

Hope this helps,

moon30

button2cute · Sep 9, 2005

Hello,
I am new at this site, but I have been searching on a topic you may be able to help me with. I work in a busy pediatric office with three physicians. We are required to follow the doctor from room to room and do his/her charting for him/her during the exam. Sometimes they tell us what to write, other times we are left guessing. I wasn't taught anything about this in nursing school and have never heard of anyone else having to do this. I am not even sure if this is within my scope of practice as I can't find anything else about it. I am getting paid a fraction of what a physician is, yet I am doing everything for them. Does anyone else have to do this I am becoming very frustrated.

Hello, All

Yes, the nurses that work with physicians at an ortho clinic, peds, gyn (sometimes not with female physicians) and others who are workmen comp physicians (as your md or against you). They follow the physician into the office or exam room, sit at the desk, the dr ask questions and perform the exam, the nurse writes as the physician dictate to her, and she signs it and order the medications as well.

I thought it was illegal, however, the nurse is following the protocal of her job title per nursing board and she is in her scope of nursing as well.

The medical physicians have poor handwriting and the nurses have great handwriting and a great speller. Yes, I say the say thing ....the physicians can go to writing classes, use a tape recorder and sent it out for typing, use a dictation phone and lastly, use a computor with a program on it....lazy butts.

That is the new trend for hospitals that say "we do not have the fund for the technology".

Therefore, you have to check with the nursing board of your state as well as look at your job requirements.

Good luck, have a great evening and day,

Buttons