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?

[RadNurse55]

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?

The chart is a legal document that you make to paint a vivid picture......so if you ever have to go to court, you should be able to read your notes and determine what happened and when. Your notes are the only facts that you will be able to stand on, so make them as accurate and memorable as possible. The more precise, the better.

The old adage is, "If you didn't chart it, you didn't do it or it didn't happen." Whenever possible, just state the facts. Never accuse, blame, point fingers, or assume anything. That is not what the chart is for. "Just the facts, maam, just the facts."

[LouisVRN, RN]

I always chart the nursing staff by the acronym we are assigned, first initial, last initial and a random number. That way should a patient get a hold of the chart for whatever reason they aren't specifically named, by in a court scenario it would be easy to find out who that person was. If I spoke to a Dr. I will always do a SBAR about why I called them and the orders I received.

[RadNurse55]

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...

And when you have to appear in court, are they going to be there to stick up for you? If you only state facts, there is no blame or finger pointing. Never chart hearsay from another employee or anything you did not personally witness. I hope this helps. If you gave report to Charlie Brown, RN or Emily So-and-so from Speech, those are facts, not finger pointing or blaming. It is all in how things are worded. You have to cover yourself professionally because when it comes down to the line, you are the only one who can protect you. Your memory is fresh now, but in 6 years after caring for thousands of other patients, are you going to remember who you notified of some situation that occurred when only your name appears on the chart?

[cherrybreeze, ADN, RN]

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 think that's the whole point of JulieCVICURN's post......you don't have a need to chart a coworker's name if you have the coworker chart their OWN observation. I don't usually use a name because the only thing I'll be saying in relation to a coworker is, "CNA reported to writer that patient complained of SOB" and the rest of my charting would indicate what I observed and did to intervene. I wouldn't be documenting someone else's findings beyond something as generic as that example, so there isn't really a NEED to use their name. In a case like that, it doesn't matter who told me, what matters is what I did.

I don't consider charting which physician you talked to to be quite the same thing. I do use the name of the physician that I spoke to, ESPECIALLY if they do not give me orders regarding what I am calling about (low UOP, c/o pain, etc). If they give orders, you can easily go back and see who you talked to, the date/time will coincide. Otherwise, it's "Dr. X paged and returned call. Updated on c/o pain 10/10 after receiving prn analgesics. No orders received." This is especially important (using the MD's name) if they don't return your page, you have to page multiple times before getting a response and it's a long time, or if they aren't addressing a concern that needs to be addressed.

[OutlawNurse86, BSN, RN]

Certain co-workers I have will chart a note like "Report given to *my name* LVN." This just annoys the fire outa me. Yeah, my name is on there because I charted for that shift, but I just don't like it when someone before or after me types that. No real reason, I just get a bad feeling from it, I just don't like it. I can't really explain it better than that.

When I chart that I've paged a Doc, I'll usually put their name. When I'm charting something that went down (like if I report a high BP and the Doc doesn't want to address it) depending on the severity of the response (ie, "Just let it go don't worry about it" [happened once]), I usually just type "Dr on call notified". They'll know what Doc it was and I won't look like I'm out to get that Doc. Thus my backside is saved .

[PMHNP10]

The chart is a legal document that you make to paint a vivid picture......so if you ever have to go to court, you should be able to read your notes and determine what happened and when. Your notes are the only facts that you will be able to stand on, so make them as accurate and memorable as possible. The more precise, the better.

The old adage is, "If you didn't chart it, you didn't do it or it didn't happen." Whenever possible, just state the facts. Never accuse, blame, point fingers, or assume anything. That is not what the chart is for. "Just the facts, maam, just the facts."

I've always had the thought that I don't want to make the defense attorney's job easy, so I omit names of people that can be easily identified (e.g., ED physician, charge RN, house supervisor, ED RN etc.). I haven't worked a floor position for quite a few years where I've been on the floor with several "staff RNs" and I honestly don't recall if I ever had to write a fellow staff RN's name or not

If you didn't chart it, you didn't do it or it didn't happen.

a fear mongering statement initiated by civ suit attorneys, as told to me by an attorney, because in fact, in a court of law it is possible to prove that something was done in spite of a lack of documented evidence, just as it is possible to prove something has not been done in spite of the documentation stating it was done; that's not to say it's a good idea to omit bits of information in your charting, because it definitely is not, but the perpetuation of this fallacy does not serve a positive purpose IMO

[bjaeram]

Certain co-workers I have will chart a note like "Report given to *my name* LVN." This just annoys the fire outa me. Yeah, my name is on there because I charted for that shift, but I just don't like it when someone before or after me types that. No real reason, I just get a bad feeling from it, I just don't like it. I can't really explain it better than that.

When I chart that I've paged a Doc, I'll usually put their name. When I'm charting something that went down (like if I report a high BP and the Doc doesn't want to address it) depending on the severity of the response (ie, "Just let it go don't worry about it" [happened once]), I usually just type "Dr on call notified". They'll know what Doc it was and I won't look like I'm out to get that Doc. Thus my backside is saved .

We were told to chart report given to....the reason it is it signifies the end of the writers responsibility for a pt. Say I gave report at 2 pm.....the next nurse didn't chart anything...the patient codes at 3pm....it looks like you were still caring for the patient at this time. If the other nurse hasn't put her name on that chart yet in the courts eyes you may still be caring for them...yes the schedule says differently but if the nurse that followed you denies getting report how do you prove you gave it?

[pielęgniarka, RN]

In school I was taught to write names. On the job I have been discouraged from doing so in the progress notes. It could be each facility has it's own policy. Every place around where I'm at we are taught to just chart "oncoming nurse, charge nurse, nurse manager, CNP, on call MD, MD here for rounds, PA, pt POA, pt wife" etc. I personally wouldn't want to see my name or initials written by someone else in a patients chart, a legal document. I only want my name on charting that I have personally completed. Of course when I take orders I document specific names on the order slip TORB to Dr. Whatshername. But progress notes... no names.

[tewdles, RN]

I've always had the thought that I don't want to make the defense attorney's job easy, so I omit names of people that can be easily identified (e.g., ED physician, charge RN, house supervisor, ED RN etc.). I haven't worked a floor position for quite a few years where I've been on the floor with several "staff RNs" and I honestly don't recall if I ever had to write a fellow staff RN's name or not

a fear mongering statement initiated by civ suit attorneys, as told to me by an attorney, because in fact, in a court of law it is possible to prove that something was done in spite of a lack of documented evidence, just as it is possible to prove something has not been done in spite of the documentation stating it was done; that's not to say it's a good idea to omit bits of information in your charting, because it definitely is not, but the perpetuation of this fallacy does not serve a positive purpose IMO

At the risk of offending you I will suggest that these are dangerous ideas to promote related to nursing documentation. You must document so as to make YOUR job easier as the professional witness, should you be deposed in a litigation. Your credibility will be injured when you are unable to provide basic facts about the case and THAT will make the opposing attorney's job easier. There is a reason that professionals are specifically named in high risk documents (OR records, resus records, etc)...because even though they can be "easily identified" later it is in the best interest of the staff and the superior respondent if those things are clearly specified at the time of care, rather than ferreted out after an incident or bad outcome. A good, complete, professional medical record has that information present.

Secondly, when documentation is incomplete there is reason to have concern. This is not "fear mongering", this is realism. Certainly you MAY be able to prove that something was done (even though it was not properly documented)...but who wants to put themselves in a position to find proof of something...years after the event...in order to preserve your license, your good standing as a nurse, your employment, or your honor? As well, because you MAY be able to accomplish something years after the fact is in no way a guarantee that you actually WILL accomplish it. Are you willing to put yourself and your license in jeopardy for a "maybe"?

Think about it...do you really want to have to PROVE that you checked that pressure dressing per protocol (or insert some other task or procedure), years later, because you were too cavalier to actually chart what your were doing as a professional nurse? Imagine, in a court of law, how a jury views a professional nurse who couldn't be bothered to chart the most basic things about the care he/she provided...and the patient in the care of this nurse suffers a serious event and poor outcome. I cannot imagine that the members of that jury would be terribly impressed.

Then imagine as that professional nurse that you must sit in the courtroom and defend your documentation. You must give a professional accounting of what was and wasn't done. You must answer the very specific questions of the opposing attorney who will be interested in helping you to look foolish and dangerous. And you must do this years later with only your documentation to guide you. Do you suppose that the jury or the judge is impressed by a nurse who is relying on memory because basic facts were omitted from the documentation and responds repeatedly with, "I think", or "I'm not sure", or "I don't know". Trust me, they will ask you if the omitted information is at all important and why you didn't bother to include it...they will ask what other things you don't bother to do in your general practice, etc.

Perhaps you do not see much litigation in psych...that is great...but please, do not promote anything but a very serious attitude about nursing documentation.

off my soap box...peace out...

[PMHNP10]

why would I be offended? I posted about documentation because I knew someone would respond thinking they disagree with me, but in fact what they say is pretty much in agreement with me (I even bold faced the word "not"; so although you went in to great detail supporting your opinion, you are not saying anything I did not say--i.e., it is never a good idea to not document thoroughly (sorry for the double negative).

"If it's not documented, it's not done. [if it's not done and it's a standard of care, you are negligent in providing care. If your are negligent in providing care, your butts in a sling]"

From the moment I got into nursing, this was what I believed because in fact it was what I was told, and I'm sure I'm not the only one, because we are made to believe that the often used statement is the gospel. Fortunately, as I've stated, it is not gospel.

my point about the malpractice lawyers is that if you are human and make a mistake and forget to document something, and you happen to get brought into court, it is not guaranteed that you will lose, but once again, in no way, size, shape or form have i ever said it is ok to document poorly

however, to expand on the topic of documentation, if your billing an insurance company and hoping to get a penny for your services, the above is written in stone, no ifs ands or buts

as for psych nursing--in fact, by the grace of God I "do not see much [any] litigation" in psych but I suspect psychiatry gets way more than its fair share of litigation; I'd actually like to see where psych ranks with radiology, OBGYN, surgery, ER, etc. if I knew a reliable source

[pielęgniarka, RN]

Oh funny, I also wondered about your statement PSYCHRN & found a link that talks about most often sued medical specialties! It's 2003, so a little out of date but a bit interesting. Basically this is the list (most often sued at the top)

Neurosurgery

Vascular Surgery

Cardiovascular or Thoracic Surgery

General Surgery

Radiology

OB-GYN

Emergency Medicine

Other Surgical

Infectious Diseases

Radiation Oncology

Cardiology

Physical Medicine & Rehabilitation

Neurology

Pulmonary

Gynecology

Pediatric Medical Specialties

Orthopedic Surgery

Anesthesiology & Pain Management

Otolaryngology

Urology

Pediatric Surgery/Surgical Specialties

Internal Medicine

Ophthalmology

Plastic Surgery

Hematology?Oncology

Pathology

Other Medical

Gastroenterology

Podiatry

Family Practice and General Practice

Dermatology

Unidentified Specialty

Nephrology

Pediatrics

Psychiatry

Endocrinology

Rheumatology

Allergy and Immunology

however, to expand on the topic of documentation, if your billing an insurance company and hoping to get a penny for your services, the above is written in stone, no ifs ands or buts

as for psych nursing--in fact, by the grace of God I "do not see much [any] litigation" in psych but I suspect psychiatry gets way more than its fair share of litigation; I'd actually like to see where psych ranks with radiology, OBGYN, surgery, ER, etc. if I knew a reliable source

[PMHNP10]

thanks for finding that; I'm guessing that source doesn't specifying nursing, so I suspect a majority of psych lawsuits come at the inpatient level because of what occurs (e.g., PRN emergency injections, force hospitalization, force PO meds [with IM as the alternative if they refuse]) as well as the side effects from medications such as hyperglycemia from atypicals, etc.; I think in the outpatient setting, folks are a bit less likely to sue because providers usually devote at least 15 minutes of 1 on 1 time to talke with the patient and get to know them and about their families, jobs, friends, etc; patients often reveal very personal info about themselves and a bond (i.e., therapeutic rapport) ideally develops, hence hopefully decreasing the likelihood of a lawsuit