Dilemma With Documentation

[carl5480]

There is currently a difference of opinion in my office, so I'd like to get a few outside opinions if I could.

I work within the wound care department in my hospital. One of my coworkers is currently on light duty a therefore is unable, per our boss, to be in a patient room in a direct care role (it's liability issue for the hospital). In order to try to be helpful, she has made an arrangement with some of our prn nurses that they will see their assigned patients and do the hands-on work while she will document on the patients.

To me this is a very dangerous situation. I feel that it is not only unethical to document an assessment on a patient you have not actually assessed, but it is also opening yourself (and the hospital) up for legal repercussions should any litigation occur. To be honest, it feels as if this is medical fraud - documenting that you saw, evaluated, and changed dressings on patients when you, in fact, did not.

Am I over-reacting to this? I know it is a somewhat common practice for, say, a physician to state that he examined the patient when in reality he only stood a few feet inside the door so he could say three sentences to the patient before leaving. Still, that does not make it right.

When this issue was brought up prior to my co-worker's return, it was my understanding that our boss told her that she should not be documenting assessments. I have not heard of any change since that time.

And a final thought: what if my co-worker documented the assessment, and then in the comment box at the bottom stated "the patient was evaluated by Jane Doe, RN." Would that be considered okay since she is acknowledging another nurse was actually evaluating the patient? Or would that be a bad move as it flags the chart for inappropriate or unprofessional behavior? What if the nurse who actually saw the patient typed out a small note that said "I reviewed the documentation by Nancy Nurse, RN, CWOCN and agree," similar to how the documentation of nursing students is signed off? (I'm still not comfortable with that, as at least in that scenario the student nurse physically performed the assessment).

Any thoughts on the issue are appreciated. Thanks!

[MunoRN, RN]

It wouldn't be appropriate for the nurse doing the documentation to suggest that they were the one who evaluated the patient, but there is nothing at all wrong with a nurse acting as a scribe for another nurse, the use of scribes is actually pretty common.

[carl5480]

So you're saying as long as you identify yourself as a scribe or the equivalent it should be fine? Would that not need to be sanctioned by superiors? It is my understanding that dictation and transcription is performed by people who have been trained in that role and who are covered for the practice under their job description.