Do you include co-workers' names when charting? How do you chart?

[rn4ever?]

When charting, do you write names of doctors/co-workers or just titles? For example, Dr. Smith informed about the situation instead of house officer informed about the situation; Charge Nurse John Smith received patient report at 1500 instead of Charge Nurse received patient report at 1500; As per night shift nurse John Doe, patient's wife sneaked in food for patient at dinner time instead of as per night shift nurse, patient's wife sneaked in food for patient at dinner time. How do you chart? Legally, are you supposed to or not supposed to include names and titles? What are your thoughts?

[mlbnocnurse]

For MD's I write Dr. _______, When referring to coworkers, I use 1st initial & last name, If I don't know (&can't find out) the last name, I chart first name RN (or RT or whatever applies). If any of my charting is used in court, I want to be able to look @ it & know who I spoke with & what they did. I was always tought to chart specifics, not generalizations.

[Quidam]

As a new employee I have a lot of trouble knowing who is who...and what the names are and as I chart and cannot put the names with a face, I generalize and HATE it. I am doing my best to get and remember names, and know which Dr. is which as I don't always speak to the ones rounding on my patients but I usually at least see them . For the exact reason mentioned above...I need to have specifics in my notes of I am ever called into question.

[MC1906]

Sounds like your attempting to have really clear and accurate charting. In this case I would say, yes...charting a name and title would be appropriate.

Try introducing yourself and asking them what their name is?? Ask a co-worker, that may also help?

[caliotter3]

For MD's I write Dr. _______, When referring to coworkers, I use 1st initial & last name, If I don't know (&can't find out) the last name, I chart first name RN (or RT or whatever applies). If any of my charting is used in court, I want to be able to look @ it & know who I spoke with & what they did. I was always tought to chart specifics, not generalizations.

Ditto this. You don't want there to be any room for doubt, especially in the courtroom.

[diane227, LPN, RN]

I chart very specifically on who I notified about what.

[silverbat]

the policy where I work is to NOT use names, but to use titles. However, I was taught to use names in school. and It is my understanding (Kick me if I am wrong) that using names is the correct thing to do.

[JulieCVICURN, BSN, RN]

I don't chart anything coworkers tell me. If someone tells me "so-and-so snuck food to the patient" I would ask them to chart it, not chart that they told me that.

[rn4ever?]

I work in Psych and patients are not allowed to have food brought in from outside. But if I think that a certain behavior is relevant to something, I document it in the chart or the written report for the next shift to know. Either way, the thing I'm interested to know is if you write your co-workers' names in the chart or not.

I don't chart anything coworkers tell me. If someone tells me "so-and-so snuck food to the patient" I would ask them to chart it, not chart that they told me that.

[NurseLoveJoy88, ASN, RN]

I got a lecture from my coworkers and DON for charting names of coworkers. I now say per 7-3 shift nurse or etc.

My facility says charting names of coworkers is like blaming them. Idk.

This is still cloudy to me...

[ayla2004, ASN, RN]

if i handed over an aspect of care labs, wound care etc any change in pt status that i have or sometimes have not informed the doctors about i write the name of the nurse i told i also perfer to name the doctor i spoke to however often it is the on call and we dont get there names.

Using the person name makes it clearar who was involved in the care.

[tewdles, RN]

If you are ever deposed you will benefit from having the names and titles of any health professional with whom you collaborated.

Any supervisor who claims that naming a professional who contributed either verbally or physically in the ongoing care of the patient is tantamount to assigning blame has a very narrow vision of what the chart and documentation actually represents.

The fact that you are new and do not know the names of many MDs or coworkers certainly makes it more difficult for you. But, it also makes it necessary for you to learn their names as quickly as possible and gives you good reason to be assertive in discovering those names.

Remember that the patient chart and your documentation is, among other things, a source of protection for the patient, yourself, and the hospital. The more specific the information the more protection it conceivably provides.

Good luck!