documenting - page 2

Hi everyone, I hear a lot of different things about how often you should document and what you need to document. I work 12 hr nights and I document an opening noted, along with a RN shift assessment flowsheet and then notes or... Read More

  1. 0
    I have a question. I had been taught charting by exception and if something was going on with a patient I was to include all parties at the bedside by name, such as Jane D. RN at bedside, or Kira CNA assisted patient to bed. This was common practice at the Hospital too. But recently I've started working at a skilled nursing facility and was asked by another nurse to not include her name in the documentation, and that even the doctors name does not appear in the nurses notes. (I'm still going to put the doctors name... I know better here) She asked I only document unit 4-East nurse as bedside, and it's just weird seeing her name in another nurses documentation. I don't understand this request, because if I'm pulled into court years later at least its specific to who assisted me at bedside.
    Last edit by ginsil22 on Feb 9, '12

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  2. 0
    what is the policy in your facility about documentation? Ours has an "exception only", so we chart as you mentioned but only made extra notes when exceptions occur.

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