Correcting Another Nurse's Charting Error??

canesdukegirl, BSN, RN · Aug 25, 2011

I will NOT chart for someone else. Period. If you need to fix it, re-open the chart and fix it yourself.

I am all about having someone's back and agree that we should all be team players, but accountability is also a big deal in my world.

Computer charting is time stamped. If I go back and change another nurses charting, it will show that I did so, and then I am accountable for that note. It is always best to let the nurse know that you caught the error, and then they can amend the chart themselves, under their own password and e-signature.

Turtle in scrubs · Aug 25, 2011

I'll give you an example. We had an urgent case where a patient was getting multiple medications at a rapid rate. Lots of nurses and docs involved at the same time. After the dust had settled I was going over the event and saw that solumedral was not charted by a nurse who I knew had given it. The nurse was long gone and not coming back for days. I called him at home, he confirmed that he indeed gave it. I charted that Nurse XXX had given the med. We have computerized charting. I charted under my name, not under his password and ID, so it was clear that I was charting for another nurse. Our system is built to allow for this.

I have done this very rarely, so when I do I always write a quick progress note explaining (just as I did above), so that if the chart is reviewed anyone can see the chain of events that took place. It is important that the medication be charted for their future care. If I don't know a medication was really given, it may be given again too soon. Or it may not be given again because the doc didn't realize it was really given and indeed the drug that turned things around. It is dangerous not to chart.

Charting by proxy is an acceptable thing to do when the circumstances warrant. I would never chart a med I didn't give in a way that made it look like I gave it. I recommend adding a progress note that makes it crystal clear the circumstances.

If you put what is best for the patient first, remember to document what was done and why, I think you will be just fine.

Isabelle49 · Aug 25, 2011

The nurse who didn't chart or charted incorrectly can go in and correct whatever on their return to work.

caliotter3 · Aug 25, 2011

If you locate the other nurse so they can tell you all this, they can just as well walk to the computer and make the entries themself. I won't chart for another nurse.

LouisVRN, RN · Aug 25, 2011

I will do it once in a blue moon, for example in a code situation. If I am able to confirm with the nurse that the medication was given and was removed from the omnicell/code cart and just forgotten to be documented but I will sign in under my name and document a comment on our emar, documented as given, per conversation with M. Smith, RN, who administered med at approximately xx:xx per phone conversation at xx:xx. I will also do a patient note saying that noticed on emar medication ordered and not given, call placed to M. Smith, M. Smith stated medication was removed from omnicell and given at xx:xx, please see emar documentation reflecting above. This is only if the nurse will not be back for several days. If the nurse is to return the following day I just ensure that they document.

rn/writer, RN · Aug 25, 2011

The other nurse can't always go in and make the correction. The system we use doesn't allow you to go back more than twelve hours. If the previous nurse has already gone home, she's stuck. I will occasionally call the nurse if something is unclear. Or she will call me in a panic to tell me she didn't chart something. For the patient's protection as well as the nurse's, I will then chart under my own name that "Per Nurse So-and-So, 5mg Ambien given at 2245." As Turtle in Scrubs said, this ensures that the patient will not receive a second dose in error.

We have bar coding for our meds, so the situation doesn't come up too often. But sometimes the system is down when the med is given. Or you see a new admission has an order in her chart that isn't in the computer yet, and you use override stock. Then you use spelling of name and DOB to verify patient ID and chart electronically when the system comes back up or the orders show in the computer. Unfortunately, we're human, so mistakes do get made.

The important thing is to chart under your own name and add a narrative that you are documenting what the other nurse told you. There is nothing deceptive about this. And it isn't considered tampering with or altering someone else's charting.

If you don't chart this information, the patient may be given the next dose far too soon or may exceed an amount of medication for which there is a limit in a 24 hour period. Or they might get more than they should if the order was written for a certain number of doses.

Protecting the patient is the most important thing. And as long as everything is aboveboard and clear, there should be no problem.

blondy2061h, MSN, RN · Aug 25, 2011

We have a system in our EMR where if someone doesn't sign a drug off that they gave you can sign it off under their name and next time they log in they'll be asked to either cosign or reject the charting. I'll do this if they specifically ask me to sign it off because they can't make it back to their computer, if they call me and ask me to because they forgot to after they left, or if they forgot to sign it off and it's literally still on the IV pole infusing right after they left.

I will not fix someone else's charting.

Turtle in scrubs · Aug 25, 2011

If you locate the other nurse so they can tell you all this, they can just as well walk to the computer and make the entries themself. I won't chart for another nurse.

Nor would I if they could walk over to a computer and chart it. Then I just say "Yo, don't forget to chart your viagra!"

But if I see that someones hydralazine is not charted and I know the person is gone, you bet I will follow up. A lot of nursing is detective work. Anyone who says "that's not my job" is just lazy. You don't need a nurse to hand someone a pill - that's a task a baboon can do. You need a nurse to problem solve and advocate for their patient.

MrChicagoRN, RN · Aug 25, 2011

Then she started talking about a scenario about if we see that another nurse has charted the wrong dose or wrong glucose level or the wrong number of tablets given or if they even forgot to document that they gave a med that you can check with the nurse to see if they gave it and if they gave it correctly then you can go in under their time of caring for that patient and basically chart that it was given and document in the notes that the other nurse has stated that she did in fact give the med.
First, why have a computer system that doesn't recognize this immediately when you are in the process of giving the medication???
Second, I don't know about you but I felt that what she is saying is that I can basically change someone elses documentation which was/is a no-no where I used to work and when I was in school. And how should I even know/trust that when I ask this nurse if she gave it that what she said is true.
I understand that but isn't changing someone elses documentation illegal, even if it was wrong??? Help me out people!

You are not changing anyone else's charting, the EMAR won't allow it. If the nurse is unavailable to correct his/her error you are only documenting that it was given according to the nurse. For example: Time-stamped at 5pm you document that Nora Nurse RN reports that the 9am Ancef 2gm IVPB was given as ordered."

If she lies, it's on her. You are charting not that you gave it, not that you know for a fact that it was given, but are only charting that she states it was given at the correct time

chevyv, BSN, RN · Aug 25, 2011

We are still in the dark ages and paper chart everything. I will not make corrections for any nurse. I do leave sticky notes and let them know. I normally catch an error from days and I'm pm's so for me to chart on something that happened on days would be just way too shady for my liking and I really really like my license :nurse:

anotherone, BSN, RN · Aug 25, 2011

Nor would I if they could walk over to a computer and chart it. Then I just say "Yo, don't forget to chart your viagra!"
But if I see that someones hydralazine is not charted and I know the person is gone, you bet I will follow up. A lot of nursing is detective work. Anyone who says "that's not my job" is just lazy. You don't need a nurse to hand someone a pill - that's a task a baboon can do. You need a nurse to problem solve and advocate for their patient.

Exactly. We can't go back after a few hours on the MAR. What's the problem here? I never had to chart for someone else while they played computer games. It was usually a case of a phone call, "omg i forgot to chart that i gave a prn at 0550" can you chart it"? we have a section in our mar allowing us to chart "given by". this happens during rapid responses/codes where the mds are giving the meds also. some don't seem to even know where to chart meds..............