Giving last name in report

[DaveICURN]

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.

[wondern, ASN]

Lots of "what ifs."...

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

Has something changed about that? I agree with the instructor.

[JoeRN8]

I think the majority of you are perhaps too paranoid. With the increasing amount of tasks we do and there are really people that are worried about a nurse report being charted? It's kind of implied at this point, although with electronic records it's almost silly. Many people give great reports. Others....not so much. Mainly I like to know what should I know that isn't charted, what time consuming tasks are done already, is there a plan of action or if not then what is pending for tests and such. My point of mentioning this is, no amount of report can truly make you always aware of everything and overreporting can also hinder care. Upstairs they give report for an hour sometimes. During which time something could happen to the patient and cause legal issue. Just get to work, get your assignment, and get moving. If you are a good nurse and are proactive then it shouldn't matter if you chart report given or not because if you ever have to look back and wonder if that will save you from legal issues then you are probably already in trouble anyway. There are many ways to find out who is responsible. If you don't think they can log who is accessing a chart at any time, you obviously don't understand electronic charting.

[psu_213, BSN, RN]

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?"

It's funny that you should bring that up. I had the "pleasure" of being deposed about a case for which the doctor was being sued. The hospital's attorney advised me that "for things such as an assessment--you do not have to prove that you went through every step of it. For example, it is acceptable to state 'I would have listened to her lungs as a part of the normal assessment,' even though you did not explicitly chart that you listened to them. The same applies for other routine issues such as verifying the patient name when drawing labs, giving report, and following isolation procedures. Just because those things aren't charted, you are able to say 'I would have done that as a part of the normal process.'"

I'm not saying the NM of the unit might want to chart "report to" notes, but, at least in this case, it was not a legal requirement.

[psu_213, BSN, RN]

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).

It is a lot faster for me to look at the assignment sheet than to look through the medial record for a "report to" note. How our EHR is structured--some people write notes on the flowsheet, others use a nurses note form--it can potentially take a little bit of (sometimes a lot of) looking around in the chart to find any given sentence. OTOH, Assignment sheets are kept up to date--it is my understanding that it is a state regulation that they be accurate for any given moment.

Assignment sheets are kept for several days. If I need to go back farther than that, it is probably not time critical that I find out which nurse was caring for the patient. In that case, I can go back to the that day in the chart and have a pretty good idea of which nurse had a pt based on who wrote the assessment, passed the meds, etc.. Also, what if the assigned nurse changes during the shift? A note may say "report to Sally, RN." Suppose Sally went home sick or was downstaffed. What if Sally did not write a note saying she gave report to Andrew, RN? What if Andrew was covering Sally for lunch when some incident happened? Do people always write notes about which nurse was covering their lunch?

It just seems to me that relying on the EHR as proof of whom was taking care of the patient at any given time is at least as, if not more, unreliable that other methods, such as the assignment sheet.

[psu_213, BSN, RN]

Has something changed about that? I agree with the instructor.

It's not necessarily true when it comes to giving report to another nurse on your unit at change of shift, etc.

[wondern, ASN]

It's not necessarily true when it comes to giving report to another nurse on your unit at change of shift, etc.

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!

[psu_213, BSN, RN]

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"...as 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.

[Ambersmom, BSN, RN]

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)

[bgxyrnf, MSN, RN]

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.

[FLorida_624]

Last names are absolutely not necessary.