Charting for another nurse

[mominsd]

I started a new job at an adult day health center. The director is telling me I need to chart for the LVN because she is older and unwilling to learn how to chart on the computer. Mind you, I am not with her when she does her patient care, but I am asked to chart for her, using a post it note that she used to jot down info while seeing the patient. I am a new grad and need advice. My common sense says NO WAY, but the director is insisting I do it. Am I playing with fire, and should I quit?

[mominsd]

Actually to complicate matters, the director suggested I chart in third person, as in, "LVN intructed pt to......LVN assessment BP 122/80, HR 76...., LVN adminstered 0.4 mg NTG.....

Does this make it even more crazy?

[nuangel1, BSN, RN]

no way.never do that

[caliotter3]

Actually to complicate matters, the director suggested I chart in third person, as in, "LVN intructed pt to......LVN assessment BP 122/80, HR 76...., LVN adminstered 0.4 mg NTG.....

Does this make it even more crazy?

No, by using wording like "LVN instructed to" or "LVN instructed pt to" she is putting the charting onus on you and shifting it from the LVN.

[tewdles, RN]

your instincts are correct...do not agree to this. the LVN needs to do her own charting...that she is "unwilling" is no excuse. if the DON is persistent then perhaps SHE needs to do the charting...she is, afterall, also a nurse AND she is the one who has determined that it is okay for this nurse to choose not to chart herself.

[smileyperson]

We have been told in school that you can chart for someone else in rare circumstances. If another nurse calls you after they have gone home for the day and asks you to add something they forgot to add to a patient's chart, you can do so, clearly writing that you are doing it by proxy for the other nurse.

Have I been fed bad information?

[Lacie, BSN, RN]

No No No!! If the LVN isnt comfortable with computers then they need to find her a class or type orientation to orient her to them and fix that issue asap. I would never chart for someone else and sign my name. I was a DON and would never ask my staff to do same nor would I permit it. The liability is too high as if you are the one charting and a legal issue arises it's your tail not the LVN as she didnt do the documentation you did. You can contact your board of nursing and see if you can find specific documentation supporting your stand and present this to your administrator. Jobs are tight but you shouldnt be asked to risk your license. Times are changing and this LVN needs to learn to change also. I've been an RN for 30 years and have had to learn myself. It can be intimidating sometimes but I felt so good once I succeeded in overcoming the dreaded computer keys lol.

[IHeartPeds87]

I have a question...why can't the DON sign for it then? Seems like they are trying to put a fast one on you.

In regards to smileyperson's post though...this is interesting...I am wondering if someone know's the answer?

[IHeartPeds87]

We have been told in school that you can chart for someone else in rare circumstances. If another nurse calls you after they have gone home for the day and asks you to add something they forgot to add to a patient's chart, you can do so, clearly writing that you are doing it by proxy for the other nurse.

Have I been fed bad information?

Can someone elaborate on this information?

[Lacie, BSN, RN]

Can someone elaborate on this information?

It's one thing to chart on your pt that "tylenol 650mg po given by So-So, RN" on your own patient but to chart on patients that you didnt have full participation in thier care or didnt "witness" you dont chart it. As far as writing a "forgotten" order taken by another nurse - NO Way. Only the Nurse taking that order should chart that order as she can write it as a "delayed" written order noting the time it was actually written to the time it was actually given. Never write a verbal or telephone order you yourself did not take as errors happen and it's your tail on the line. In this instance the poster is being asked to do near all the charting for another staff member because "they arent comfortable with the computer". It's one thing to chart incidentally if another staff member does something for you (of which you state that in the chart) but to be asked to do the charting is another another. I used to do expert witness for standards of nursing care in court rooms and let me tell you we would have torn a chart and the nurse apart in a case like this.

[Whispera, MSN, RN]

If you chart for the LVN, besides all that has been mentioned above....you have no idea if she actually DID everything you're asked to chart, if you didn't see it happen. If you chart that it happened, you're saying you saw it. Don't do this. Not only would it put you in legal difficulties, but it might be encouraging lack of patient care.

As for charting for the nurse who has already gone home, the nurse should chart a late entry next time he/she comes in. But, as we all know, the patient might have been discharged by the time the nurse comes back. I would chart what the nurse said when she called, such as: "at 1400, received call from previous nurse, Jane Doe, RN. Doe stated she noticed patient had _____ at _____and ____ was given at _____. Doe stated patient felt relief at ____." All this keeps it as what the nurse told not, not charting as if you did whatever was done.

[mamamerlee, LPN]

Unless you were given the other nurse's computer password and are charting verbatim what she is telling you, then the answer here is "NO". I charted for another nurse who fell and injured her wrist, under her password. Therefore it was her charting; we did refer to proxy charting.DO NOT under any circumstance chart for someone else for anything you did not personally witness. If the facility can't afford to train this other nurse, let them provide her with Dragon Speak, and she can talk to the computer!

As for someone calling in after their shift, it is possible to chart for them, as noted above. If possible, have someone listen in on your conversation.

[tewdles, RN]

As others have posted...you do not chart what others have done. If the nurse calls and tells you that she did "such and such" you may chart that she said that, just like in the example provided by Whispera. Nothing more. Any further documentation must be generated BY THAT NURSE. If the patient is discharged or dies before her next shift she can go to med records and make the late entry. Remember that the chart is a legal document. You can be held accountable for anything that you write in it. Any nurse who has been deposed in a legal case has a heightened appreciation for his/her charting and interaction with the patient record.