Charting based on other's assessment????

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    Wondering if anyone else has been faced with this. My psych facility requires the RN to do a shift "nursing reassessment" form on each patient. This includes things like their history and/or risk of SI,HI,SAO,psychosis, falls etc. Then there is the mood, affect, thought process, thought content, medical concerns etc. The nurse is expected to then write a narrative of some sort that would basically support the need for the patient to remain in treatment, or the appropriateness of discharge for the UR dept. to use with the insurance company. Unfortunately, because of the staffing, the nurse that is being asked to do this charting, may not ever even see the patient, or may only have a brief opportunity to observe while the patient receives medications or is seen going out to smoke. Soooo, the nurse is basically supposed to read the group notes written by techs(if they have then done when you're trying to do your notes), ask the tech about the patient (if you are so lucky to see THAT person). So, the bottom line is that the nurse is being told to write documentation based on other's observations - or you can go back to the shift before and write the same thing they did. Never in all my many years of nursing in many different settings have I been told I am to sign my name to and assessment that isn't mine. If THAT isn't enough, the nurse is also supposed to give PRN meds based on the tech's report that the patient needs one. I would love to hear if anyone else has experienced this nonsense!
  2. 2 Comments so far...

  3. 0
    Wow Marilyn,
    Never have I hear that it is acceptable to give medications based on a Techs assessment(which is not allowed) Even an LPN in many facilities MUST go the RN before giving anything PRN, even Tylenol.
    The idea of documentation based on others reports also seems like a violation but I do not have chapter and verse to support that. Have you contacted the Nursing association or Board of Nursing in that State?
  4. 0
    Obsolutely wouldn't happen for me! There is nothing that could ever convince me to sign my name to assessments that I have not done myself. Absolutely NO WAY! Ever!


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