Charting un-witnessed behavior

[Pkirk618]

One night I was charge nurse. The nurse on the other side of our two winged facility charted that she had an issue with a patient and charted appropriately. Next day, the powers that be find out that there's a history with the kid (escalates often) that when he acted up with my colleague on the other side, her charting wasn't suffice. But based off what she told me, it was good.

I knew something relatively small happened and it was charted. Maybe even an incident report was completed. But that nurse handled thing pretty spot on.

But because they are seemingly trying to CYA for stuff happening before our shift and nitpicking at the things that did happen to our shift, they asked me to chart on something I didn't see. And I didn't see it---and I don't think its right that that ask me to compromise myself/license for the sake of CYA. I get I'm supposed to ensure all charting gets done but I do this based on the information I get from other nurses. If something new arrives to someones attention, those nurse managers should use their time to track that nurse to make the charting more accurate. I can't chase nurses down that work different shifts anyway.

What would you do? Is this even remotely right? What nurse practice acts in Illinois protect me? Sorry, pressed for time and I need advice. You guys got the condensed version but the bottom line, I wasn't there for anything they might be worried about so I never saw this patient.

Thanks.

[Jory, MSN, APRN, CNM]

You cannot chart something you didn't witness....period. That defeats the purpose of charting.

Once, upon a chart review, I was told I didn't chart something properly but my hospital was huge on doing things the right and legal way. So when I went in I put the CURRENT date and charted "late entry" and added information and ended it in "added for clarification" and signed my name.

It was something that I recalled perfectly so I didn't have a problem with it and the hospital deserved to have the correction.

[jadelpn, LPN, EMT-B]

You can only chart as a late entry "Chg Rn (your name) for shift, RN (their name) reported to me that xtz, reviewed intervention, RN acknowledged understanding of same"

If administration has issue with what the RN charted, then she can go back as a late entry and add any details that she may have missed.

[Pkirk618]

why late entry? I'm referring to charting on something I didn't see. Any Nurse Practice info out there someone can refer and help me?

[morte, LPN, LVN]

they are backing you up.....they are telling you that is the ONLY thing you can do....cant doc what you didn't see.

why late entry? I'm referring to charting on something I didn't see. Any Nurse Practice info out there someone can refer and help me?

[loriangel14, RN]

You CANNOT chart on something you didn't witness.Period.

[BluegrassRN]

The only way I would chart unwitnessed behavior is a situation like "Jane, RN reported to me that pt struck her on the arm and yelled 'Get out of here!'. "

[psu_213, BSN, RN]

Unfortunately, for me, the generalizations in the OP are a bit too vague for me to really understand what is going on. A couple things I can say:

1. You cannot chart on as if you were there unless you actually witnessed it. You could say "It was reported me by (Sally, RN or Mike, CNA, etc.) that pt screamed, RN performed this intervention, pt responded with this behavior, etc." You can't chart as if you were there if you were not.

2. Perhaps your facility wants you, as charge, to 'follow up' on the charting of other nurses. However, they are nurses. They learned how to chart in school. The facility should educate those other nurses on what they want in the charting. In the end, it is that other nurse's responsibility to be sure his/her charting is up to those standards. If they want you, as charge, to review that charting, so be it; but in the end, it that nurse's duty to make sure his/her charting is complete.

[Ruby Vee, BSN]

You cannot chart that you witnessed the behavior if you didn't, but you can chart that "J. Doe, RN reported that patient struck her in the face and then threw his meal tray into the hall. Doe, RN has large bruise on right side of face and 2 cm laceration above right eye. D. Jones, CNA reported hearing loud voices coming from patient room and seeing meal tray flying out of room. J. Smith of housekeeping reports seeing meal tray on floor outside of room. When asked, patient denies striking the nurse or throwing the tray, but stated 'If it did happen, it's because she's so ugly.'" You can also chart anything you did to follow up, such as making behavioral contract with the patient.

[BrandonLPN, LPN]

Don't we chart what CNAs report to us all the time? Isn't that why we call them our "eyes"? For example, I might chart "CNA reports resident combative with HS care" or "CNA reports resident refused shower x3". Since the aides can't write nurses notes, it's your duty to chart what they report to you. Of course, you also need to document what you, the nurse, did with that information.

[jadelpn, LPN, EMT-B]

Late entry is standard practice for charting done well after the fact--meaning it happend yesterday, last week, last month. (and I would google "Joint Commission rules on late entry charting" and see what it says). As others have noted, as a charge RN, you can chart that the RN reported it to you, what intervention occured and the outcome. Sometimes it is even prudent that if one of the nurses under your charge reports a major incident with a patient, you may want to then go and see said patient, and follow up on that information. And chart same. Other times the Rn will say "charge RN aware, intervention discussed and implemented with a positive result". If administration is asking you to essentially "make stuff up" I would be very, very cautious of that.

[jadelpn, LPN, EMT-B]

Topic: Develop a late entry policy to ensure compliance - www.hcpro.com