ok to use names in charting? - page 2
We were recently told in a nurses mtg that we should not use the proper names of coworkers in charting. For instance; an ex was made "this nurse,and nurse (so and so, RN) were unable to find... Read More
Sep 23, '05Wow. This is an interesting discussion. I am currently taking my pre-req's to go back to school for nursing (am on waitlist.) I'm going from detailed oriented accounting/secretarial jobs all my life to nursing. It's neat to see people's views on this, because I am a worry-wart, and always afraid of forgetting a detail, and getting punished for it. I'll have to see what I am taught, but believe me, from what I have seen in the "real world" you need to look out for #1, because no one else will. I have a feeling, just knowing myself, that I would be more detailed, rather than less detailed. Not that I would be the type of worker to just get others in trouble, but if someone messed up, and I had to appear in court for it, I would DEFINITELY want MY ducks in a row.
Sep 23, '05Quote from oldnurse newnurseThis exactly what the defendant attorney will want to see in the medical record.
....... we were told to use the name or first initial and last name of a co-worker ........
Sep 23, '05Quote from siriThen what would you recommend, Siri?This exactly what the defendant attorney will want to see in the medical record.
Sep 23, '05I'm not particularly worried about legal liability, probably because Australia isn't as litigious as the US - at least for now.
I always write the doctors' details (eg "BP at 2400 195/95; covering RMO J. Brown [bp 1234] contacted - recheck in 30'"), primarily to cover myself, having been badly burned once before by a doctor who denied having been contacted.
As for fellow nurses, it depends on the circumstances. I say that even though I can't remember an occasion where that would be necessary. Although I'd put specifics (like who saw a patient fall) on the incident report, I think I only write something like "witnessed fall" in the notes.
This is a really interesting thread
Sep 23, '05Quote from BabyRNTessHi, BabyRNTess,Then what would you recommend, Siri?
I knew when I submitted my reply that it could possibly be misinterrpreted. But, I did it anyway. Sorry. I will clarify.
The defendant is the institution and you (the nurse). The defendant attorney will want to see that you charted appropriately. In other words, if you are under scrutiny, the plaintiff attorney is looking for the fact that this (name of the actual offender) was left out of the medical record, therefore you must have committed the act and no one else.
Entering the first initial/name and the last name with credentials is appropriate.