Published Feb 7, 2014
I give report to some nursing staff and they only give their first name as the person receiving report. Nurses where I'm employed argue that you don't need full name (e.g., Report given to N. Nurse, RN). Is this true with documentation?
nurseprnRN, BSN, RN
Some reason why you can't ask what the last name is, or if you are too shy to do that, to check the schedule book or the previous shift duty roster?
anon456, BSN, RN
I always ask them to spell their last name. That way I get it correct and let them know I need it. I also will get pages returned from resident MDs and they will say, "This is Jane." and I reply, "Hi Doctor, thank you for calling me back. Can I get your last name please, for documentation? Oh thank you Dr. Smith. I appreciate it Dr. Smith" and hopefully they get the point.
Ruby Vee, BSN
Are you sure you need the last name? When we transfer patients to another unit, we get only the first name. If there is ever any question about which Debbie we gave report to, their signature shows up in the electronic chart. And their assignment sheets (which have to be kept for seven years) will also show which nurse had that patient.
I agree with Ruby Vee. My hospital utilizes Epic Hyperspace, and as such, when scrolling through the patient's progress notes, the first and last name of every nurse that has ever seen the patient is there filed beneath their nursing note (in addition to every physician, dietary tech, case manager, or social worker). When I accept a patient, or sign off on a patient, I typically write a note (transfer or acceptance) and include the first name of the nurse and the unit, that way if there is any confusion, I know who/where to refer to.
The main reason why we document anything is for protection from litigation, protection for both the facility and ourselves with a secondary concern simply being clarity of actions for patient care. The question on whether we should include full names and titles comes down to how confident are you that you can prove you handed over care or received report from an individual with only a first or last name.
Again, it never hurts to tell the nurse you're receiving report from that you'd like his/her first and last name for your acceptance/transfer note. If they dispute you on it, ask for the charge/resource nurse, and find out which nurse you received or gave report to.
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