Giving last name in report - page 7

In school, I was taught to chart the first initial, last name, and license of the nurse receiving Pt care. This was explained that if the chart was called into court and I gave report to Brittany... Read More

  1. by   psu_213
    Quote from wondern
    I agree until the 'etc.' part. That to me is really a given when the new nurse takes over starting with her assessment note, and that is written. I never charted report given to so and so at the end of shift on the floor, but I did transfers from PACU a lot and it was standard protocol to write who was given report, both first and last name, always.
    I don't even know how one would realistically chart that they reported to who at the end of shift unless they went back after report because a lot of times one doesn't even know who will be assigned to that patient next anyhow.

    I'm going home after report not back to charts thats for sure!
    Sorry, I should have been a bit more precise in my language. By "etc" I mean charting what was said in report, where report was done (I've seen nurses chart "bedside report to Sara, RN" if to prove the point that they actually did bedside report), and other aspects of giving report on the unit. When transferring pt's to another unit, whether it be from the ED to floor or from the floor to the ICU, I would chart the first name of the person to whom I gave report. If I was transferring I patient from the ED to another facility, the law requires me to give report, so I always charted to whom I gave report (again, first name only). My post earlier was only to state that I don't see the value in charting to whom I have report when handing off a pt on my unit...and just because that report was not charted does not mean it was not done.
  2. by   Ambersmom
    We use Epic at my places and DON'T have to chart who hand-off was received from or given too, as much as I hate Epic glad we're not doing it (yet)
    Last edit by Ambersmom on May 9 : Reason: typo
  3. by   ~♪♫ in my ♥~
    Quote from bugya90
    We use Epic and part of the flowsheet is who you gave to report to/who you received report from and what time. I only chart first name and title "Sally, RN" and the approximate time. There are nurses who just chart "oncoming shift" but I don't think they are supposed to be doing that.
    We, too, use Epic but there is no place in a flowsheet for a name. We use a standardized phrase that only says, "Day Shift RN" or "NOC shift RN."

    OP, just do what your department or hospital policy dictates. I wouldn't give you my last name mostly because you'd end up asking me three times how to spell it and still get it wrong.
  4. by   FLorida_624
    Last names are absolutely not necessary.