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Can another nurse chart on behalf of you?



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No. 10
from dscrn
Old Oct 02, 2009, 08:23 PM

Default Re: Can another nurse chart on behalf of you?
Originally Posted by caliotter3 View Post
My DON rewrote a nurse's entry and wrote in the entry that she was rewriting it. I thought it was irregular at the time; we other nurses talked about it, but nobody would say anything to her. In that particular instance, the DON was present when the occurrence took place, so she could have made an entry anyway. But what made it wrong, in my mind's eye, was that the original entry left the chart for parts unknown. I couldn't understand why the DON would make the statement she did and remove the other entry.
This is known as chart tampering-anything that is written on a pts chart is considered a legal record!
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No. 11
from Truegem
Old Oct 03, 2009, 12:26 AM

Default Re: Can another nurse chart on behalf of you?
What Oz said is exactly what I am saying...I do believe this is ok. I would have to know more about what the DON wrote and why and her role in the whole thing to give an opinion on it.
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No. 12
from BunnyRN
Old Oct 03, 2009, 11:06 AM

Nurse Re: Can another nurse chart on behalf of you?
Originally Posted by Oz Janine View Post
Why can't you say 'Phone call received from RN Jones. She stated that pts dressing was changed today at 0300?'

But what if tomorrow RN Jones totally denies ever making that phone call. Do you how many nurses deny knowing a pt. condition, during end of shift report. The next day when getting report, they'll say, "you didn't tell me". I have this RN on my floor, who is near retirement, where we "nurses" have to repeat ourselves, to make sure that she totally understands us. After giving her report, I also write it up in the chart, that report given to RN....

In addition, to cover myself, I call the doctor, tell the Charge RN, and write it up in our daily log book, for follow ups!!!
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No. 13
from nursel56
Old Oct 03, 2009, 05:03 PM

Default Re: Can another nurse chart on behalf of you?
Wow, BunnyRN. I think the nurse you are talking about would be an unusual case, because most nurses, I think would remember making a phone call, and have no reason to deny it, since it was to make sure her fellow nurses are up to date with the accuracy of nursing care provided to the patient.

I don't know how "near retirement" that nurse is, but if she is not providing safe care it can't be ignored or covered up by the other RNs. How can you guys do your jobs if you have to be calling doctors, doing write-ups, telling charge nurses to cover yourselves because she regularly neglects to do things? Yikes!
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