Giving last name in report

Nurses General Nursing

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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 RN Anywhereville, Hospital, that there may be multiple people of this name at the same date and time report was given.

This has been my norm for report, and I have only recently ran into opposition. While giving report I, as usual, requested the nurses name for posterity. It's been a favorite of mine since the princess bride. The nurse, in no uncertain, terms reported "I'm not obligated to give my last name." I paused, then gave my last name and gave report. So I noted first name, hospital, and unit.

My question,

What is your opinion on giving last names for report?

I have heard the concern of the nurse on the other side being a "creep" and stalking the nurse. So safety I understand. Just want second opinions on my own understanding.

The thought of an RN, or any any health care worker for that matter, covering up their last name on their ID badge with tape is very unprofessional. It sounds illegal actually, not to mention disrespectful. What kind of dignity is that providing your patient?

If your patients are stalking you FTLOG have them arrested. Their illegal behavior does not change the laws and rights of other non-stalking patients who have the right to know who is providing their care.

The vast majority of patients (or their families) do not stalk or threaten their nurses. However, available data shows that a nurse is likely to be subject to LATERAL violence in their workplace during the course of their career, from their CO-WORKERS, and that LATERAL violence is a significant problem in nursing. It is also not unknown for nurses to abuse patients.

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Specializes in Emergency, Telemetry, Transplant.
What exactly could go wrong with a patient in the first few minutes, or even hour of your shift, that you feel you might be blamed for if you didn't chart exactly what time you assumed care?

You said a vast majority of the time it doesn't matter. Do you have any specific examples of when it did?

And I really don't think charting "report received from Mike, RN" would really protect a nurse. Suppose that is charted at 725 am. At 748 am, the pt goes into a deadly arrhythmia. Now that nurse has to answer why they didn't go into that room for 20 minutes after getting report.

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What exactly could go wrong with a patient in the first few minutes, or even hour of your shift, that you feel you might be blamed for if you didn't chart exactly what time you assumed care?

The poster you quoted gave examples of what could go wrong in her second, third, and fourth paragraphs.

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And I really don't think charting "report received from Mike, RN" would really protect a nurse. Suppose that is charted at 725 am. At 748 am, the pt goes into a deadly arrhythmia. Now that nurse has to answer why they didn't go into that room for 20 minutes after getting report.

mrsboots87 gave examples of how charting handoff using the full names of both the off going nurse and and the receiving nurse, and the time of handoff, would protect her. I think her examples were pretty clear. And yes, of course, there will always be a charting gap if something happens to the patient between the time the nurse receives report (promptly documenting the full name of the nurse she receives report from) and the time the patient is found to be in a deadly arrhythmia (assuming the nurse does not go into the patient's room to provide care after receiving report up until the time the patient is found in a deadly arrhythmia), just as there will be a charting gap between the last time the nurse assessed/medicated/rounded/provided any other type of care, etc. and the time the patient is found to be in a deadly arrhythmia. The point is that by documenting full names it is clear which nurse has responsibility for the patient at a given time. If you are the off going nurse and have handed over responsibility of the patient to the oncoming nurse and documented this properly, it cannot be construed that the patient is still your responsibility if he/she goes into a deadly arrhythmia 30 minutes later. If you are the oncoming nurse and have received responsibility for the patient and have documented this properly, it cannot be construed that the patient is still the responsibility of the off going nurse if the patient goes into a deadly arrhythmia 30 minutes after you receive report.

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The poster you quoted gave examples of what could go wrong in her second, third, and fourth paragraphs.

No, not really. Nothing specific.

She did mention a patient detoriated around shift change, which happens all the time. She failed to show how she might have been blamed for it and how charting when she took over made a difference.

Anyway, that we're off topic from the original post, so I'll move on.

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Specializes in SICU, trauma, neuro.

Am I the only one who was never taught to document handoff? For an inter-facility transfer maybe, but not every change of shift. My thought is if it's so important to CYA, why stop at the name? We should probably transcribe our entire report if that's the case...otherwise how does anyone REALLY know that I advised the oncoming RN of every important detail?

As for hiding our last name from pts, I do think it's unprofessional.

Someone mentioned judges; police officers too -- they always introduce themselves with last name. I'd venture to guess judges and LEOs piss of MANY more people than nurses do. Social workers do too. I was actually investigated by CPS once (and cleared quickly, thank God!) the social worker had her full name both on her badge and on business cards. I hear moms can get extremely mama bear-ish when faced with children being removed; my college roommate's mom even carried, she was so concerned for personal safety. She still provided her name.

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Specializes in Trauma, Teaching.

The majority of the times we have someone demanding a last name, is a very angry patient or family with alcohol imbibement involved. We mostly just say the first name, and the name of the ER manager, and encourage them to call in the morning. I also say it is in the medical record, and they have a right to their records, and will need to contact the medical records dept. when the chart is complete. Not giving out my name (rather unique) to an intoxicated howling maniac. If really needed, I'll call the clinical supervisor or house supe to deal with them.

My hospital does not put last names on the front on the badges. We do have an icon at the top of the computer where a simple click opens up the "report given to", with a drop down list of names. TYpe in the first few letters and it populates by itself. Same for report to the floor for admits. Transfers to other hospitals (not just back to nursing home) all require names of who we gave report to, time and date. Gets audited for regularly.

Don't know why the OP's person was being so obnoxious about it, unless they had such bad habits they didn't want anyone to be able to follow their paper trail easily.

I have been deposed on charts before, never made it to court. Mine was sometimes the only legible one on the old paper charts. I even had another nurse tell me she wouldn't sign a legible signature for that very reason. I consider that dishonorable. It is one thing to avoid a threatening person, totally different to not take responsibility for your own actions and charts.

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Specializes in Neuro ICU and Med Surg.
This is very true, but it appears that some facilities find it acceptable for nurses to document using just their first name on the patient's medical record, and, if this is the case, I find it odd that this practice is permitted when the medical record is a legal record/document that draws so much scrutiny, that may be audited/requested by authorized persons/subpoenaed, etc. This is not what I was taught was legally acceptable. It also makes it harder for the patient/their representatives to determine who the nurse was that provided their care at a given point in time (which I presume is the objective of some people). I would think that an attorney would have quite a lot to say about this.

I am also surprised that there is not a handover documentation standard that requires the full name of the nurses or at least the first initial and last name of both the nurse who is handing over the patient's care and the nurse who is assuming the patient's care, that is enforced in the same way other EMR documentation standards are enforced, particularly as handover is a time when miscommunication between health care team members has been shown to happen, with the result being errors in care that have the potential to or actually do result in harm to the patient. We follow SBAR format at handover with the intention of providing necessary/important patient information at shift change and minimizing errors in care that can harm the patient; surely recording the first name and last name or first name initial and last name of the nurses giving and receiving report contributes to patient safety, as there is no doubt as to who was the patient's nurse at a given time if questions arise.

The same principle applies to name badges (with the exception, as you stated, of psych and corrections).

My first middle and last name show up on anything I chart on the EMR. Our hospital took last names off ID badges after nurses were having issues being contacted on social media, or receiving calls to their personal numbers after patient's were discharged. I have no issue with telling someone my last name if I need to, but I get the issue with nurses being contacted by patients outside of work.

Again I had no issue with my first and last name on my badge, but our system stopped this and only put last initial after some incidents. I have no reason to chart the last name of the nurse I gave report to. That can easily be figured out by the assignment sheet and a first name. I don't ever chart who I specifically gave report to.

I work rapid response, and will chart, something like "Attempt made at establishing IV access, and after 2 tries unsuccessful. RN Jamie notified and she states she will contact MD for further orders." I have no need for her last name.

Everything I chart is electronically entered and time and date stamped so there should be no question as to my name in the chart at that time. If management needs to know which "Jamie" had the patient they can check the assignment record.

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Specializes in Neuro ICU and Med Surg.
I just thought of a situation in which I was regularly asked my last name when working in the hospital- when the lab called panic results in. They still butchered the spelling every time, even though I spelled it out for them.

I did once have a CPS worker refuse to give me his first name when he accepted a report of neglect that I filed. He said "I only go my Mr. Jones" (or whatever his last name was) and directed me to address the written report my state requires that we follow-up with to him in that way.

Everytime lab slaughters my last name. Every. Single. Time. I just give up LOL. I even say it extremely slow and try to get them to repeat it back. Stupid Polish last name LOL.

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Specializes in Emergency, Telemetry, Transplant.
Am I the only one who was never taught to document handoff? For an inter-facility transfer maybe, but not every change of shift. My thought is if it's so important to CYA, why stop at the name? We should probably transcribe our entire report if that's the case...otherwise how does anyone REALLY know that I advised the oncoming RN of every important detail?

I know some people that charted a "report to..." note when handing a pt off in the ED. On the floor, I cannot remember a single time someone charted that they gave or took report at change of shift. I have also never seen it charted when another nurse is covering a lunch. I'm not saying it never happens--based on this thread, obviously it does. However, if it is as vital as some people describe, I would think that I would have seen it at some point during my career.

I too was wondering about charting what was handed off in report. Suppose I tell Mary in report that "yesterday, when helping Mrs. Jones out of bed to go to the bathroom, she got really dizzy when she stood. It occurred again for me last night when I helped her up." Just after report, Mrs. Jones rings for assistance to get up to go to the restroom. Mary doesn't supervise Mrs. Jones closely enough, and Mrs. Jones gets dizzy, passes out, and suffers injury. Mary swears up and down that she was never told about Mrs. Jones' orthostatic issues. Should I have charted that I told Mary about this? At that point, there is an almost endless list of things that I could chart about, saying that I passed it on in report--never knowing which one(s) will become important during the next shift. Now I have to do this for all 5 patients I am handing off!?!

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I have no reason to chart the last name of the nurse I gave report to. That can easily be figured out by the assignment sheet and a first name. I don't ever chart who I specifically gave report to.

I work rapid response, and will chart, something like "Attempt made at establishing IV access, and after 2 tries unsuccessful. RN Jamie notified and she states she will contact MD for further orders." I have no need for her last name.

Everything I chart is electronically entered and time and date stamped so there should be no question as to my name in the chart at that time. If management needs to know which "Jamie" had the patient they can check the assignment record.

These are my thoughts about the above: The patient's EHR is a legal record. So if there is a lack of clarity in the EHR documentation as to who the patient's nurse is at a given time it will be obvious to someone reading/reviewing the patient's chart (the fact that there is an assignment sheet that shows which nurse is assigned to which patient is beside the point). If it is necessary for another health care team member to find out who (first and last name) was the patient's nurse at a given point in time in order for them to provide timely care for the patient, they will be using the patient's medical record to find this information, and if that information cannot be derived from the patient's medical record this can ultimately delay the patient's care as extra steps have to be taken to find this out (you are saying that you don't chart the last name of the nurse you give report to, and anyone who needs to know this information should find the assignment sheet for that day). Would a nurse who was asked in court about this feel comfortable answering, "We don't need to document the last name of the nurse we give report to on the patient's medical record because it is on the assignment sheet, and the manager knows who the nurse is?"

The question also arises when it is the patient (or their representative) who wants to know the name of the nurse caring for them at a given time. As mentioned earlier in the thread, patients have the legal right to know the full name of the nurse caring for them (Muno mentioned exceptions being psych and corrections), and patients and their representatives have the right to obtain a copy of their medical record. Suppose a patient or their representative reviews their chart and wishes to know the full name of the nurse to whom you reported that you had difficulty starting their IV, and all that is documented is "Jamie, RN." In my opinion it is pretty arrogant to assume that the patient/their representative should be willing to accept just a first name for the nurse who was providing their care, and I certainly wouldn't accept this if I was a patient or their representative and had reason to know this information.

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These are my thoughts about the above: The patient's EHR is a legal record. So if there is a lack of clarity in the EHR documentation as to who the patient's nurse is at a given time it will be obvious to someone reading/reviewing the patient's chart (the fact that there is an assignment sheet that shows which nurse is assigned to which patient is beside the point). If it is necessary for another health care team member to find out who (first and last name) was the patient's nurse at a given point in time in order for them to provide timely care for the patient, they will be using the patient's medical record to find this information, and if that information cannot be derived from the patient's medical record this can ultimately delay the patient's care as extra steps have to be taken to find this out (you are saying that you don't chart the last name of the nurse you give report to, and anyone who needs to know this information should find the assignment sheet for that day). Would a nurse who was asked in court about this feel comfortable answering, "We don't need to document the last name of the nurse we give report to on the patient's medical record because it is on the assignment sheet, and the manager knows who the nurse is?"

The question also arises when it is the patient (or their representative) who wants to know the name of the nurse caring for them at a given time. As mentioned earlier in the thread, patients have the legal right to know the full name of the nurse caring for them (Muno mentioned exceptions being psych and corrections), and patients and their representatives have the right to obtain a copy of their medical record. Suppose a patient or their representative reviews their chart and wishes to know the full name of the nurse to whom you reported that you had difficulty starting their IV, and all that is documented is "Jamie, RN." In my opinion it is pretty arrogant to assume that the patient/their representative should be willing to accept just a first name for the nurse who was providing their care, and I certainly wouldn't accept this if I was a patient or their representative and had reason to know this information.

Lots of "what ifs."

What if a member of a care team or family member wants to know who brought the patient a drink of water? Or who helped them to the bathroom?

This sounds like the nursing school instructor who insists that "if it wasn't charted it wasn't done."

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