Charting

[Fancy Face]

:monkeydance: Do you nurses chart and document findings and assessments for other nurses when the unit is very short staffed (even if these are not your residents?) Just curious.

[RNHawaii34]

If I didn't assess the resident, I won't even dare chart anything for that resident. unless if by any circumstances, it was endorse to me, then I will do an assessment, and complete the charting. follow the facility's protocol, just to be safe. did that answer your question?

[Fancy Face]

I should have worded it differently. Say you come on a floor halfway thru a shift to help out in anyway, and the only other nurse is swamped and asks you to do her charting for her while she finishes her meds, treatments are done, etc. So, you sit down to chart her findings b/c you are just coming on the floor, and you havent had time to assess the patients yourself, and soon as you chart for her you are to go to a different floor to help them out with their charting. By the nurses findings I mean: lung sounds clear, pedal edema +2 noted, dressings dry and intact, etc...thanks for any input, I didnt feel wholly comfortable with it, but the charting had to get done...

[NicoleRN07, RN]

If I didn't do the assessment, then I don't chart it.

[cschuess]

I won't chart unless I did the assessment. Some people feel that the charge nurse should do all the charting for the floor when they actually have a charge nurse but I am not comfortable with this unless it's a generalized note such as a medicare note summarizing that resident for the week.

Imagine being pulled into court and having to state that you never assessed the person you charted on...wouldn't want it to be me!

[morte, LPN, LVN]

the only way around this, that i can see, is to act only as the transcriber....ie, write the information, but DO NOT SIGN. the nurse who did the work then would have to read and sign each or your transcriptions.

[cschuess]

the only way around this, that i can see, is to act only as the transcriber....ie, write the information, but DO NOT SIGN. the nurse who did the work then would have to read and sign each or your transcriptions.

I really think that's a bad idea...all they need to do it look at the handwriting...and if that nurse doesn't sign off you will be looked at as a "careless nurse" who leaves unsigned notes in charts.