Is it illegal to mention nurses names when charting on a patient?

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Is it illegal to mention nurses names when charting on a patient?

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9 Answers

Specializes in Tele, ICU, Staff Development.

When documenting, it's crucial to follow your facility's specific policies. Different healthcare organizations may have unique guidelines about what to include in a chart, who can be mentioned, and how to appropriately document contributions from various team members. Reviewing these policies regularly can help you understand what is acceptable in your context.

Always check with your facility's policies on documentation to ensure compliance. 

While it's generally permissible to mention nurses' names, several important considerations exist. First and foremost, any documentation in a patient's medical record must adhere to the principles of relevance and necessity. This means that any mention of a nurse must directly relate to the care provided to the patient. For instance, documenting their involvement may be appropriate if a nurse administered medication, performed a procedure, or participated in care planning.

Sometimes, documenting in the EMR or at the Pyxis station requires another nurse's electronic signature.

Avoid including personal details about the nurse or using the medical record for non-professional comments. Charts are legal documents and should serve as accurate, objective patient care accounts. They should not be a platform for personal opinions or informal commentary about staff members.

In summary, while mentioning nurses' names in patient charting is allowed under certain conditions, it's essential to focus on relevance, adhere to facility policies, and ensure that documentation serves its primary purpose: to support patient care and maintain professional standards.

Always consult your supervisor or documentation specialist if you have concerns about what to include in patient records.

Best wishes,

Nurse Beth

 

Specializes in Medsurg.

No, if another nurse does something to your patient, ie drsg change, delivered a treatment, gave a med, a short note stating that Sally, RN changed the drsg to... This covers you if that nurse does not chart that they did it and lets the rest of the care team know, if they actually read the nurses notes, that. It was done. 

Also, if a suit is filed for whatever reason there is a record of who did what when and why.

Remember this " If it's charted it's done, if it's not it never happened legally". Charting is your best defense and evidence. Example: I had changed the drsg from a wound vac to a wet to dry drsg per the last written order in the chart. The Dr blew his top when he rounded. I was called to my manager's office. We were in the process of changing to EMRs, and had checked both for the most current order. Took my evidence to the meeting and was backed up by my manager. We later found out that another nurse had taken a verbal order to place the wound vac but never charged the order or placed a note stating so. Since then that Dr has treated me with increased respect since I read the orders as they are in the charts.

Specializes in Patient Safety Advocate; HAI Prevention.

When my husband was hospitalized last Summer for terminal esophageal cancer, an OT visited him.  The staff seemed to be on  a mission to "rehab" him in one day, so they could justify discharging him home.  He could barely stand up.  I had just asked for help for him to get back into bed, when that OT arrived. I had found him upright in a chair, which he had not been doing because of weakness....and his head was lolled onto his uneaten lunch tray.  He was exhausted and weak.  She came in chirping "do we want to try some steps?"   I made it very clear that he did not want to do steps.  She said "I am speaking to him, and I said I am speaking FOR him".  Because of that conversation she documented in his medical record, and named 2 RNs who supposedly agreed with her, that "the patients wife is unkind".   I wish I could put those three so called professionals in a room and tell them exactly what happened that day and beyond.  They would all be ashamed of themselves. 

References to another nurse are fine. Identifying a nurse by name in a patient's chart is inappropriate.  Phrases such as "previous shift nurse stated...", "covering nurse provided medication X..", or "assignment 2 nurse assisted with" are appropriate ways of describing another nurse's actions. If anyone needs to know who, specifically, that nurse was, they would be empowered to discover the information beyond the chart (I.e. an administrator or attorney). This is true for ALL clinical staff. Document "PCP ordered...", not "Dr. Smith ordered...". Document "PT evaluated for gait training.", not "Kevin Jones, PT evaluated..." and "Per surgeon, pt to follow up with PCP.", not "Dr. Black ordered follow up with Dr. Grey."

Specializes in OR, Nursing Professional Development.
SpaceCadet77 said:

Identifying a nurse by name in a patient's chart is inappropriate.

Why would it be inappropriate to identify a nurse by name? When we do patient care handoffs during surgery for 15 minute or meal breaks, the documentation requires what was included in the handoff and who gave handoff to whom.

Specializes in Psychiatry, Community, Nurse Manager, hospice.
KathyDay said:

When my husband was hospitalized last Summer for terminal esophageal cancer, an OT visited him.  The staff seemed to be on  a mission to "rehab" him in one day, so they could justify discharging him home.  He could barely stand up.  I had just asked for help for him to get back into bed, when that OT arrived. I had found him upright in a chair, which he had not been doing because of weakness....and his head was lolled onto his uneaten lunch tray.  He was exhausted and weak.  She came in chirping "do we want to try some steps?"   I made it very clear that he did not want to do steps.  She said "I am speaking to him, and I said I am speaking FOR him".  Because of that conversation she documented in his medical record, and named 2 RNs who supposedly agreed with her, that "the patients wife is unkind".   I wish I could put those three so called professionals in a room and tell them exactly what happened that day and beyond.  They would all be ashamed of themselves. 

That is a good example of what never, ever should be put in a chart. 

SpaceCadet77 said:

References to another nurse are fine. Identifying a nurse by name in a patient's chart is inappropriate.  Phrases such as "previous shift nurse stated...", "covering nurse provided medication X..", or "assignment 2 nurse assisted with" are appropriate ways of describing another nurse's actions. If anyone needs to know who, specifically, that nurse was, they would be empowered to discover the information beyond the chart (I.e. an administrator or attorney). This is true for ALL clinical staff. Document "PCP ordered...", not "Dr. Smith ordered...". Document "PT evaluated for gait training.", not "Kevin Jones, PT evaluated..." and "Per surgeon, pt to follow up with PCP.", not "Dr. Black ordered follow up with Dr. Grey."

Why?

SpaceCadet77 said:

References to another nurse are fine. Identifying a nurse by name in a patient's chart is inappropriate.  Phrases such as "previous shift nurse stated...", "covering nurse provided medication X..", or "assignment 2 nurse assisted with" are appropriate ways of describing another nurse's actions. If anyone needs to know who, specifically, that nurse was, they would be empowered to discover the information beyond the chart (I.e. an administrator or attorney). This is true for ALL clinical staff. Document "PCP ordered...", not "Dr. Smith ordered...". Document "PT evaluated for gait training.", not "Kevin Jones, PT evaluated..." and "Per surgeon, pt to follow up with PCP.", not "Dr. Black ordered follow up with Dr. Grey."

But you have no real justification for saying this other than someone told you this a long time ago. 
You can't justify being SUPER specific about every microscopic thing we are expected  to chart (gave a warm blanket, flushed IV, clipped right thumbnail, 16 BMs with peri care each time, Tylenol at 16:13 due to pain level of 3 with complete relief of pain within 35 minutes, etc…) and then suddenly say "oh except names, those must be top secret only available by subpoena.”

It makes no sense. 

SpaceCadet77 said:

References to another nurse are fine. Identifying a nurse by name in a patient's chart is inappropriate.  Phrases such as "previous shift nurse stated...", "covering nurse provided medication X..", or "assignment 2 nurse assisted with" are appropriate ways of describing another nurse's actions. If anyone needs to know who, specifically, that nurse was, they would be empowered to discover the information beyond the chart (I.e. an administrator or attorney). This is true for ALL clinical staff. Document "PCP ordered...", not "Dr. Smith ordered...". Document "PT evaluated for gait training.", not "Kevin Jones, PT evaluated..." and "Per surgeon, pt to follow up with PCP.", not "Dr. Black ordered follow up with Dr. Grey."

Disagree.

When making an appropriate note of important details (which they are or else I wouldn't be wasting time documenting them at all), it is completely prudent to refer to other HCPs by name. Maybe the lesson should be that if you're writing random stuff involving other staff members where it isn't important enough to document their name, you might not need to write it at all.

This makes me quite curious where/how you came to your understanding of this subject.

 

Specializes in Mental Health, Gerontology, Palliative.
KathyDay said:

When my husband was hospitalized last Summer for terminal esophageal cancer, an OT visited him.  The staff seemed to be on  a mission to "rehab" him in one day, so they could justify discharging him home.  He could barely stand up.  I had just asked for help for him to get back into bed, when that OT arrived. I had found him upright in a chair, which he had not been doing because of weakness....and his head was lolled onto his uneaten lunch tray.  He was exhausted and weak.  She came in chirping "do we want to try some steps?"   I made it very clear that he did not want to do steps.  She said "I am speaking to him, and I said I am speaking FOR him".  Because of that conversation she documented in his medical record, and named 2 RNs who supposedly agreed with her, that "the patients wife is unkind".   I wish I could put those three so called professionals in a room and tell them exactly what happened that day and beyond.  They would all be ashamed of themselves. 

You were way nicer than I would have been. 

If someone had of pulled this that on my mum I would have asked something along the lines of 'Can you explain why you think its appropriate to insist a patient with terminal lung cancer with cerebral mets gets up and walks so you can tick your boxes"

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