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?

[psalm, 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...

Not blaming them...but documenting who did what, who helped with what.

[**new**]

No. This "chart every detail because you'll need it when you go to court" is nonsense that is the result of being brainwashed, I'm afraid to say. Being VERY specific in your general, everyday nursing charting is actually bad and more than likely will be used AGAINST you in a court case. That aside, truth is, you'll probably never, ever go to court in your lifetime anyway.

I see a lot of people use the "protect your license" reason to back up their statements. PATIENTS DON'T CARE ABOUT YOUR LICENSE. THEY WANT MONEY. THEY WANT THE HOSPITALS MONEY, AND THE DOCTORS INSURANCE MONEY.

That's all.

[RescueNinja]

I chart Dr. ______, but will only say RN or RT or whatever their title is, not names. This is just how I was taught...a lot of nurses in my unit will put full first and last name and designation when charting about others though.

[tewdles, RN]

No. This "chart every detail because you'll need it when you go to court" is nonsense that is the result of being brainwashed, I'm afraid to say. Being VERY specific in your general, everyday nursing charting is actually bad and more than likely will be used AGAINST you in a court case. That aside, truth is, you'll probably never, ever go to court in your lifetime anyway.

I see a lot of people use the "protect your license" reason to back up their statements. PATIENTS DON'T CARE ABOUT YOUR LICENSE. THEY WANT MONEY. THEY WANT THE HOSPITALS MONEY, AND THE DOCTORS INSURANCE MONEY.

That's all.

Make sure you choose a nursing specialty from the bottom of that list posted here if you want to live like "you'll probably never, ever go to court in your lifetime". I have worked in a couple of areas where litigation DOES happen and have testified in a case involving a physician's office. That nursing staff was REALLY scrambling...there were phone calls and conversations which were apparently very incompletely documented...some not at all.

You are correct, they do want money to compensate them for the poor care or malpractice that they suffered. However, when the patient sued the doctor and the clinic...and won money...and the doctor and the clinic discovered that the nursing documentation was incomplete and it hurt them in the case, the nurse LOST HER JOB. When a L&D nurse I worked with had some questionable documentation in a bad outcome delivery not only did she lose her job, but the hospital contacted the BON. There was some sort of investigation...I don't know all of the specifics and tried to stay VERY clear of that case.

The bottom line for me is that when I have been deposed the chart is my best friend...the chart contains the information that I require to recall the circumstances and events of a patient's care. Thankfully, I work in a VERY low risk for litigation area now. For my peers in acute care...don't be paranoid...just be precise.

[KathleenL]

OK...I know this blog is very old but I have run into this problem at my LTC facility. I am an MDS Nurse and lead the IDT Meeting. With computerized documentation I was instructed by our Corporate Nurse to document who attended the meeting. The dropdown box for this documentation happens to be under "progress notes". I have been documenting Lori A/SW; Anne H/DTR; Kris L/ACD...etc. Some of the attendees are up in arms that I am using their names, despite the fact that they also sign in, using their full name and title, on a paper sign in sheet. I took a course entitled The Legal Aspects of Nursing Documentation several years ago and it was an eye opener. The facility used one of their attorneys to teach the course, they selected a patient that had been taken care of by several nurse in the class, reviewed the documentation and held a mock trial. Those that documented well did well, those that didn't...well one of them ended up in tears. The bottom line was we were taught to use names, full names actually. Are there any definitive guidelines, other than that which they taught that day, that I can refer to?

[xxMichelleJxx]

Whenever I am referring to a coworker I always write their name.

Example: INR level x. Dr. Fluffy made aware.

When referring to nurses, I write first initial, last name, followed by RN.

Example: M. Smith, RN

Yeah, if you are new it can be difficult to get everyones name. I usually will ask the nurse what their name is.. Or ask a coworker what someones name is.

[KathleenL]

I am not new...using the computerized documentation is new. Having a quarterly IDT Meeting is actually required by the State & Federal Guidelines...we can get cited if we don't have them. I know all the attendees' names, they just don't like me using them. Again, we also use a paper sign in sheet, which they sign with their full name & title. I am baffled as to why me documenting their names on the computer bothers some of them, but it does. I am trying to find some documented guidelines to support doing this.

[KathleenL]

Please see my post below. Thanks!