Documenting info

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As student nurses, what are we allowed to actually document, like in the real pt chart? I did an Accuchek test and our instructor doesn't need to be there to witness it. We were "trained" so we can relieve some nurses duties on the floor. The nurse of the pt I did the Accuchek on told me I could initial in the MAR that I was the one who did the Accuchek on this pt. Now I'm afraid I did something wrong because I didn't have my instructor co-sign it but this particular nurse did. Will I get in trouble?

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Specializes in Emergency Dept. Trauma. Pediatrics.

I have no idea how policy is where you are, but on my last clinicals we did the accuchecks, the nurses made a list of the patients and room numbers of the ones they needed and we wrote their numbers next to their names and gave the sheet back to the Nurse.

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Specializes in L&D/Maternity nursing.

yes, we charted. Any interventions, med passes or assessments. Our instructor would then go back and add her initials by our chart/notes.

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