Can another nurse chart on behalf of you?

[Truegem]

Let's say you forgot to chart something. Can't you call the charge nurse and have her write "dressing changed at 0300." per N. Jones, RN and then she signs her name too? (My example isn't the greatest, but you know what I mean.)

I have heard that this is acceptable, but my peers are saying no.

What if you forgot to chart something very important and you can't get back to the hospital because you are going on vacation?

It seems to me this should be ok.

In fact, I'm sure I read somewhere that this is acceptable, but I don't recall where I read it.

Thanks, Patti

[VivaLasViejas, ASN, RN]

Generally, no.

Instead, you'll need to make a late entry in the chart, which by the time you get back from vacation, will likely be somewhere deep in the bowels of the medical records department. You ask them for the chart and explain why, write your note with the current date and "late entry for date/time" and sign. The charge nurse cannot write a note for you, she did not see you do the dressing change (or whatever you forgot to chart); in fact, no nurse with any smarts is going to risk her/his license by charting something for another nurse unless s/he personally witnessed it.

The reason for this is CYA---if a malpractice case were ever to be brought to a court of law, the veracity of a nurse who charts something s/he did not see or do would be seriously questioned, which casts a bad light on the rest of that nurse's testimony to say the least. The take-home lesson here is simply, do your own charting, and if you forget something---and we all do from time to time---rectify it as soon as you possibly can.

[Truegem]

I'm sure I've read somewhere that it's ok. The nurse doesn't need to have witnessed that she saw you, she is just writing what you tell her. She will indicate this in her charting. Also, you can co-sign it when you get back. I'm sure I read somewhere that it's ok, I'm going to ask the BRN.

Thank you for your response.

[sharihamill22]

At my facility anyone can chart if you give them express permission. They type in my login name(they have no access to my password) and chart that I gave the medication, treatment, etc. and that they charted this occurence. This allows for the occurence to be charted without interruption of the patients' care.

[caliotter3]

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.

[noreenl]

What did the original writer have to say about her note and the DON rewrite?

[BabyLady, BSN, RN]

At my facility anyone can chart if you give them express permission. They type in my login name(they have no access to my password) and chart that I gave the medication, treatment, etc. and that they charted this occurence. This allows for the occurence to be charted without interruption of the patients' care.

Honestly....that is false charting.

Someone else that didn't witness the event is entering information into a chart and signing your name without any indication that someone else entered the information.

Do you go back and check it?

Probably not...b/c if it ever went to court, you sure as heck can't use the "Susie Q typed it in wrong" as an excuse.

Because the attorney for the Plaintiff would say, "But it's YOUR initials!!!"

[Darknights]

Why can't you say 'Phone call received from RN Jones. She stated that pts dressing was changed today at 0300?'

[nursel56]

Rewriting an entire nurse's note, charting that you are rewriting another nurse's entry is pretty bizarre. If the DON was present for whatever transpired relating to the patient, why wouldn't the DON just write her own note? If her intention was to C her A, all it really did was add to the general impression of sketchiness.

As far as forgetting to chart a treatment or med, yes we would call, because if you don't know whether the nurse gave the med and forgot to chart it or didn't give it altogether, that's a risk for error. They would make note of the communication from the preceding nurse, not charting that they had given the med or treatment. Then the nurse can initial it when she comes in again.

[BunnyRN]

I wouldn't take the chance because sometimes some nurses forget to do their work. I've come across some patients that denie certain treatments/medication given/done. Therefore, I will chart my own notes. Leave to each nurse to chart his or her note. Like someone posted earlier in court, you will be on your own. Can't blame it on someone else, when your name is on it.

Better to do a "late entry" to cover yourself.

[dscrn]

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!

[Truegem]

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.