Documenting care provided by another nurse

Nurses General Nursing

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This question is for any Nurses really up on Nursing documentation.

I'm a new nurse, I got a pocket guide book from hcmarketplace that described how to chart care provided by another nurse if that nurse calls and asks you to chart an entry she forgot to do. The book stated after you write the note to sign and then have that nurse co-sign.

Well I did this yesterday and when I went back to work I had a message from our DON to draw a straight line through it and write mistaken entry/he stated it was not legal to chart care provided by another nurse.

Now the book says you can....So I was just wondering has anyone else done this and know anything about this kind of documentation or is it true that it is not legal?

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Specializes in critical care.

Nope never did this, and wouldn't ever do this. i don't care what the book says, make certain you stay within facility policy. Lots of times facilities have differing policies for certain items of care, those are the guidelines you need to follow.

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Specializes in ICU/ER.

The only time I have ever charted for a different nurse was on my pt when the other nurse did something. EX: 20gauge IV started by Suzy Smith RN . Then Suzy did not chart it, I did.

But as far as taking a phone call in by a fellow nurse saying "Hey can you chart I gave their Vicodin at 1600" no I would not do that.

even if your book says that, follow your hospital policy, after all that is who you are working for.

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Specializes in Home Care, Hospice, OB.
the only time i have ever charted for a different nurse was on my pt when the other nurse did something. ex: 20gauge iv started by suzy smith rn . then suzy did not chart it, i did.

but as far as taking a phone call in by a fellow nurse saying "hey can you chart i gave their vicodin at 1600" no i would not do that.

even if your book says that, follow your hospital policy, after all that is who you are working for.

i totally agree! i, too, have charted when a co-worker has helped with a patient of mine, when i have observed the care. if someone's nice enough to start an iv, i don't mind writing it up, exactely as above!:bowingpur

otherwise, no way!

the most i would do is document what i personally know to be true and accurate (n. nurse reported telephonically at 0840 that the 0600 dose of ancef was infused at 0630 today, omitted in error from mar. ~~~~~~signed~~~)

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Specializes in critical care.

Ditto (prior 2 posts)!!!

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Specializes in Telemetry.

Telephonically...lol...never heard that word before in my life. I guess one learns new things daily. Is that really a word?:chuckle

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Specializes in Home Care, Hospice, OB.
telephonically...lol...never heard that word before in my life. i guess one learns new things daily. is that really a word?:chuckle

yes, 'tis! :rolleyes:

adverb--"of, via, or conveyed by telephone"!!:typing

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Specializes in Telemetry.

Ok, i googled it. I had never heard that word before. It just sounds funny. Thanks for teaching me something new!!!:bowingpur

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Specializes in ER; HBOT- lots others.

i hate doing that. there are times when i have been asked to document a med given, esp narc's, in my preceptorship, i told them no. i explained myself. one older nurse was like "its not a big deal, you know i gave it". you know what?? I DONT KNOW! not saying she took it, but what if she dropped it and was going to re-order and give another, and didnt; or left it in her pocket and forgot...heck no!! sorry. wont do it. my job, my license. worked VERY hard and LONG for it, aint gonna lose it cuz you are too lazy to log in and do it yourself.

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Only the nurse who provided care/assesment can do charting.. Since you were not the RN who carried out care, you are not able to chart for the RN on her behalf

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