Can Someone else do a nurse's charting?

[karentou]

I've been a nurse for 20 years and just came across something at a new job that bothers me. one of the nurses has a broken arm and is in a cast. Management is keeping an extra MHT on staff when this nurse works. (MHT=mental health tech, not a nurse but like a nurse's aide). this "tech" is "assigned" to this nurse. she does the nurse's charting for her. I overheard the tech say "I'm getting pretty good at signing her name for her." I have lots of issues with this nurse even working with a broken arm (it is a psych hospital and not safe for the rest of us, among other things.) However, I feel the tech doing her charting is a legal issue. any thoughts on this?

[amoLucia]

I wonder what your risk management dept thinks about it?

[Farawyn]

The nurse shouldn't be at work.

[roser13, ASN, RN]

The tech who is charting all of the nurse's assessments needs to be charting as a scribe. Co-signed by the nurse. A very legal device used by all since the debut of EMR.

[MunoRN, RN]

There is nothing wrong with someone being the one that actually writes down or types a nurse's charting, what matters is if the source of the content of the charting is actually the nurse or not. Generally the nurse, Doc, NP, etc who is using is scribe should review the charting for accuracy.

[APRN., DNP, RN, APRN, NP]

The answer is, yes. The nurse cannot delegate the actual physical assessment, but can have someone record the assessment as long as the nurse legally signs off on it as accurate.

[KelRN215, BSN, RN]

Surgeons and Radiologists dictate their reports all the time. I don't really see how this is any different. As long as the nurse reads it and confirms its accuracy it seems ok to me.

[RiskManager]

The risk manager does not have a problem at all with this concept. I would want to see the MHT sign the note as a scribe, and to chart that the RN reviewed and approved the note, assuming that the RN is incapable of signing the note.

[Pangea Reunited, ASN, RN]

I don't see how it's any different from using a computer to "write" words for you ...assuming the nurse has final approval of what's charted.

[karentou]

Thanks everyone. I didn't look at "their" charting to see how the tech is writing it. But I know the nurse can write a little with the cast on. so perhaps this is all on the up and up. I agree though with whomever said the nurse shouldn't be working. in psych, and probably other areas of nursing, it's a safety issue. There are other questionable practices that i feel are going to contribute to some big issues down the road...med errors and accidents waiting to happen. I've voiced my concerns about to this to management. So far, the only response I've gotten is: You can come in early to give yourself more time to get things done. really?? i already work 12 hour shifts. I am not coming in early just to get my job done.

[Here.I.Stand, BSN, RN]

I've voiced my concerns about to this to management. So far, the only response I've gotten is: You can come in early to give yourself more time to get things done. really?? i already work 12 hour shifts. I am not coming in early just to get my job done.

Oh. Heck. No. Esp if they don't plan on paying you to come in early.

[Julius Seizure]

Im surprised that they are willing to pay a tech to be assigned to just this nurse.

When I was on crutches, my hospital refused to let me come in even to do a desk job.