using names when charting

  1. Hi,
    Quick question; when you all chart, do you put a name to a person?
    Example: Bob, nursing assistant, placed foley. Or do you just chart nursing assistant placed foley?
    I was taught not to chart the actual person's name in the chart. Also, does anyone know of any professional websites on legal issues related to charting? thanks in advance!
  2. Visit djsrn profile page

    About djsrn

    Joined: Aug '04; Posts: 31
    med-surg rn

    35 Comments

  3. by   Mandee
    I always put the persons name myself.

    Mandee





    Quote from djsrn
    Hi,

    Quick question; when you all chart, do you put a name to a person?
    Example: Bob, nursing assistant, placed foley. Or do you just chart nursing assistant placed foley?
    I was taught not to chart the actual person's name in the chart. Also, does anyone know of any professional websites on legal issues related to charting? thanks in advance!
  4. by   TracyB,RN
    hmmm, good question... Think I will do a search for a site on charting.
    I am sure each state has some different twists to their charting requirements.
    Personally, I have used things, like "charting nurse inserted 16 fr foley catheter without difficulty & return of 100cc cloudy, yellow urine."
  5. by   fergus51
    I put the actual person's name. If this ever goes to court how are they going to know who did what if there were 5 nursing assistants on duty?
  6. by   live4today
    Sometimes I have put names of staff in my charting, and sometimes not. Depends on what I'm charting about.
  7. by   meownsmile
    I only use names when something was reported to me by another staff. There is no need for me to chart who inserted a foley if they have done their own work and charted the foley insertion in the first place. If they havent charted it I will remind them and have them chart their own procedure. I only need to chart that the foley is in place and patent (with drainage discription) at this time.
    I might chart elevated temp reported by (last name and title only) and reported to dr by phone (with or without) new orders recieved.
  8. by   djsrn
    thanks for all the responses. I too chart "charting nurse saw" or "LPN" reported to me". One of you responded you chart the person's name cuz if there are 5 nursing assistants on duty how would they differentiate who they were talking about in court" I just don't see putting a person's name down and making it easier to get someone in trouble. Just like when you have a med error. you don't put it in the patient's chart, you make out an incident report.Does this make sense to anyone?
  9. by   Kudra
    for routine procedures that another nurse has done for me (foleys, IV starts, drsg changes), i chart who completed the procedure (first initial, last name, designation) and any thing reported to me (J. Doe, RN, reported to writer that wound appeared free of signs of infection and healing)... anything more complicated and i ask the person to chart themselves...
  10. by   RN92
    Just remember, this is your chart as well. If you are sitting in front of a judge and jury ten years from now - you need to be able to use that nurses note to recall the days events. If you are charting factual information, it shouldnt matter if you use names.
  11. by   ?burntout
    If someone placed a foley for me (if I am tied up in an emergency or whatever), I chart the person's first name, last name and credentials. Or sometimes I will use the first initial of their first name along with their last name.
  12. by   LPN1974
    [QUOTE=djsrn]Hi,
    Example: Bob, nursing assistant, placed foley. Or do you just chart nursing assistant placed foley?
    QUOTE]

    I realize this is off the question you asked, but I was wondering if the state you live in, are nursing assistants allowed to do catherizations?
  13. by   Bjo
    Quote from djsrn
    thanks for all the responses. I too chart "charting nurse saw" or "LPN" reported to me". One of you responded you chart the person's name cuz if there are 5 nursing assistants on duty how would they differentiate who they were talking about in court" I just don't see putting a person's name down and making it easier to get someone in trouble. Just like when you have a med error. you don't put it in the patient's chart, you make out an incident report.Does this make sense to anyone?
    I don't think it is about getting someone in trouble. I think the real issue would come down to ownership of your nursing practice. I agree with meownsmile. If they do their own work, they need to document it. If I am charting in reference to something I've done, I simply document "Foley cath inserted ....." then finish the note. I feel that it is implied that if I am charting it, then I did it.
    I would absolutely document a name if I was charting about what another nurse did, saw, said, or was involved in.
  14. by   BittyBabyGrower
    If we do a task for someone else, we have to chart ourselves. Our legal is of the mind that anyone could write any other person's name in the chart. The only exception is in the case of an emergency.

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