Documenting Another Nurses Med Administration

BrandonLPN, LPN · Dec 12, 2013

It sounds to me like they're just transcribing written documentation into the computer system. I don't think that's illegal.

SoldierNurse22, BSN, RN · Dec 12, 2013

If ever you document for someone else, it needs to be stated as such. If you document for a drug given in a MAR, for instance, you should be able to append a note to the administration that states something along the lines of "given by Jane Doe, RN".

Also, if you are charting for someone else, you should have actually witnessed the care that you're describing...otherwise, how would you know? So a more accurate example would be "given by Jane Doe, RN. Witnessed by John Smith, RN".

classicdame, MSN, EdD · Dec 12, 2013

your friend needs to review the nurse practice act, or call the BON, for that state. Very thin line. Why don't they just use paper MARS when computer is not available and let medical records scan them in later? For one thing, they are paying nurses to do clerical work.

Not_A_Hat_Person, RN · Dec 12, 2013

I work private duty, and I document care given by other people, usually family members, all the time. It's usually something like "Mother started that client received med x at y time" or "Nurse A gave med B."

KelRN215, BSN, RN · Dec 13, 2013

A buddy of mine who is an LPN at a clinic informed me that his boss had him document another nurses medication into their system. My friend told me that for the past 6 months the nurses at his clinic were unable to document certain med injections because their clinic was switching over too a new system of documenting pt information. So from what he told me most of the nurses documented every injection on paper until the the Tech team got the system working too allow the nurses to document their injections. So now the nurses need help inputting late info into the system and the clinc has delegated the task too my friend and a few other LPN's. Is it ok by law for these nurses too input info on med they didn't administer?

What kind of injections were these? Vaccines? I don't see a problem with transcribing information documented on paper to a computer.

P.S. To = a preposition, too = also.

Columnist · Dec 13, 2013

Moved to Nursing and Patient Medications for more response.

akulahawkRN, ADN, RN, EMT-P · Dec 13, 2013

A buddy of mine who is an LPN at a clinic informed me that his boss had him document another nurses medication into their system. My friend told me that for the past 6 months the nurses at his clinic were unable to document certain med injections because their clinic was switching over too a new system of documenting pt information. So from what he told me most of the nurses documented every injection on paper until the the Tech team got the system working too allow the nurses to document their injections. So now the nurses need help inputting late info into the system and the clinc has delegated the task too my friend and a few other LPN's. Is it ok by law for these nurses too input info on med they didn't administer?

While I'm no legal expert by any means, I would expect that as long as the computer entry has some kind of note that indicates that it's a late entry/transcribed info and that the medication was given by another named person, things should generally be OK, as long as the paper records (or scanned images) are also kept available for as long as the statute of limitations requires. Otherwise, I would be very, very hesitant to do that kind of data entry.

If called to testify, I'd want to be able to say that I saw the original and I entered the information into the computer based on what I saw on the original, and here's the original record or image of it.