Charting

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I am working with a nurse that hasn't been charting for entire shifts, sometimes 12 hours. Is this legal? Should I tell my boss?:confused:

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Specializes in Neuro ICU and Med Surg.

No this isn't legal. Yes it needs to be brought to the bosses attention.

May I ask is this paper flow sheet charting, or just a note not being written?

I cannot imagine not charting for my whole shift.

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Specializes in Surgery - some medicine.

This is not legal, so you have to tell your boss. Even if you chart by exception, there has to be something to chart on otherwise the person wouldn't be in a hospital - like respiratory for respiratory problems etc.

And you should always chart your assessments!

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This is computerized charting. I did go ahead and tell my boss. The nurse was called into the office. I don't know what was done, and don't know how many days she went without charting. I personally saw 5 charts without any documentation. Thanks for your help:up:

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Specializes in Surgery - some medicine.

Hello Murrays,

I am glad you went ahead and reported the nurse who didn't chart. It is putting a bad light on the whole unit if one member is not working properly. I hope everything will work out for you.

Ruth

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