Emergency Room Urgent Care/charting legalities

[Sam5352]

I work in a hospital ER that has a "fast track" area, staffed by a P.A., a R.N., and an ER tech. We are using the T System of charting. The P.A. sees the patient, the tech does the dressings and splints, etc.,and also can type up a discharge instruction sheet using Logicare computer program. The R.N.'s major role is giving meds and giving the patient the discharge. My question is how much charting is the nurse legally have to do? Must she legally do the assessment portion of the T sheet. If not how is she libel if she leaves it blank...If you are not familiar with the T System, it is a complaint oriented charting system. My co-workers are having a difficult time leaving areas blank, because we were taught if you don't chart it, you haven't done it. Anyone know the legalities in an urgent care setting??

[Sam5352]

No one has any information about this?

[momoftriplets]

try posting this in the ED forum, more er nurses would probably look at it.

[MAGIK GIRL]

I work in a hospital ER that has a "fast track" area, staffed by a P.A., a R.N., and an ER tech. We are using the T System of charting. The P.A. sees the patient, the tech does the dressings and splints, etc.,and also can type up a discharge instruction sheet using Logicare computer program. The R.N.'s major role is giving meds and giving the patient the discharge. My question is how much charting is the nurse legally have to do? Must she legally do the assessment portion of the T sheet. If not how is she libel if she leaves it blank...If you are not familiar with the T System, it is a complaint oriented charting system. My co-workers are having a difficult time leaving areas blank, because we were taught if you don't chart it, you haven't done it. Anyone know the legalities in an urgent care setting??

if you are talking about the t sheets that the doc uses than no, you are not responsible to fill them out. if it is a nursing t sheet, than yes you are.

if it is a doc t sheet, you should be doing some kind of assessment for your notes. as for how much should you chart, your hospital should have a protocol about notes, assessments and vs. fast trac is a nice assignment, though there is alot of turn over. i like when i am assigned there. it is a nice break.

good luck! :balloons:

[Baltimore Nurse]

if you are talking about the t sheets that the doc uses than no, you are not responsible to fill them out. if it is a nursing t sheet, than yes you are.

if it is a doc t sheet, you should be doing some kind of assessment for your notes. as for how much should you chart, your hospital should have a protocol about notes, assessments and vs. fast trac is a nice assignment, though there is alot of turn over. i like when i am assigned there. it is a nice break.

good luck! :balloons:

I work in the ER also and we have a fast track area that is staffed very similiar, The PA does most of the work, when I am assigned to the fast track area I rarley document. I often think about my liability, but the truth of the matter is that the doctor does the assessment and unless I feel that the patient is going to admitted or that the patient is sicker than "Fast Track" patient usually is I do not write a note. The exceptions to this rule are: abnormal vital signs, IV medication/lab work, excessive pain medication... I usually write a note regarding those issues.