Data entry / charting for others

Nurses General Nursing

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Where i work the day nurse is often very busy and is unable to enter the pt's she has seen that day into our computer charting system. we do keep a hand written daily log. Its isn't very big and while some times it has enough room to put all the information on other times it seems to be lacking.

I have now been told it will now be the second shift nurses (me) responsibility to enter all of the pts for the day into out computer charting system. I don't mind helping the busy first shift out but am a little worried about liabilities or legal issues. just wanting to get your guys thoughts or experiences in this matter.

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Specializes in Advanced Practice, surgery.

Moved to general forums for better response

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Specializes in RN, BSN, CHDN.

Sorry I wouldnt chart for anybody else, how do i know they did what they said they did I wasn't there. I doubt it is legal to do somebody else's charting, is it?

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Specializes in LTC, Nursing Management, WCC.

I won't even sign off other nurses orders. If the AM nurse forgot to sign off their order, I leave it out for them to sign the next day. I don't chart for others and I don't have others chart for me.

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No Way! You cannot accurately chart for another nurse like this. Refuse it! The only time I have charted for another nurse is when another nurse assisted one of my pts or performed a treatment on my pt and then didn't chart it herself. In which case I documented that Nancy Nurse RN started IV to lt hand w/#20g. Take a stand on this now or they will start trying to get you to "bend" more rules.

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Specializes in midwifery, NICU.

You can only Legally chart what happened during your shift..you were not there during other shifts, therefore, that is not your responsibility, and is dangerous to your career and your patients wellbeing.

These charts are LEGAL documents, can be called to court over issues for a great many years, and if your name is next to something that you were no part of, but signed anyhow, if the effects are detrimental...then your career and ass is down the swannee!

Take responsibility only for your own actions, sign your notes meticulously, leave no room for error! And get that first shift to write their own bleedin' notes!

Take care babe!

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Specializes in Community Health, Med-Surg, Home Health.

I remember seeing something to this effect in my textbook Success in Vocational Nursing, I believe. I was not comfortable with it, and hope this doesn't become a requirement for us. If I was not there, I would not do it, and if I didn't perform the task for someone else's patient, I would not wish to do it, either. I swear, if it became policy, I would write right in that chart "As per policy, Nurse so and so requested that I chart that she did such and such", and even then, that would mean that I would have to follow up to see if it was actually done. Not comfortable at all. Call the BON, see what they say.

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Specializes in MICU for 4 years, now PICU for 3 years!.

The only thing I can think of, maybe in the software you're going to be using, there will be some way to chart that this info is from x nurse... at my hospital we use EPIC and there is a button you can click on if you are charting something you did not specifically do, but are putting in the computer. It shows up that you charted it, but the other person did it. It's more of a pain in the you know what to do it that way, so I don't think it's used much.

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