Nurses note question

[Inquisitive one]

I work in long term care and last evening I read a nurse's note that mentioned the names of other nurses who assisted this nurse with an assessment. For example, patient's BP 62/palpable. "Jane Doe RN" also got same results. Reported to charge nurse "John Doe RN" and patient sent to ER. Should a nurse write another nurses name in a note? I've also seen things like reported to supervisor " supervisor's name" or DON "DON name" aware. What are the legal implications regarding this? I know I wouldn't want my name in someone elses note. I'd prefer to write my own. Any feedback?

[krob0729]

If another nurse helps me with a pt I always state their name and title. That way the pt cant say that I did a procedure that I wasn't allowed to do by law, and by mentioning the other nurses name and title there is a (witness) as to what was done. When i replace a g/t for another nurse who is not certified, she charts that I did it, then I go behind her and chart what size i used and the results.

Hope this helps some.

[nursedenes]

personally, I do not write another nurses name in a chart because she assisted me. If I need her name I will ask her to do a documnetation. I recnetly did vital signs on an unresponsive patient and was surprised to see vital signs done by "my full name". What is that for. We never always documnet who did a vital signs that way, so I am assuming this nurse, same title as mine is just looking company in case there is a court issue. I will raed what my state nurse act says though.

[jonesecho, RN]

I work in long term care and last evening I read a nurse's note that mentioned the names of other nurses who assisted this nurse with an assessment. For example, patient's BP 62/palpable. "Jane Doe RN" also got same results. Reported to charge nurse "John Doe RN" and patient sent to ER. Should a nurse write another nurses name in a note? I've also seen things like reported to supervisor " supervisor's name" or DON "DON name" aware. What are the legal implications regarding this? I know I wouldn't want my name in someone elses note. I'd prefer to write my own. Any feedback?

I think especially if the patient is critical and you have gotten another nurse to confirm your opinion-it can be good charting. To me it would be the context in which you use another nurses name. the example above is a good reason to use their names as far as I am concerned. It sounds as if the pt. is critical and the nurse had someone else check who agreed with the finding. she or he the charted situation was reported to charge nurse which just shows good chain of command before pt. sent to ER. -------------Now, if you would give an example of a critical situation where the nurse charting did not agree with another nurse, etc. and then she is charting on that it would be inappropriate. Then the nurse would need to use other means to address the situation. Charting also has no room for gossip, or opinions. Charting should be relevent and to the point with the patients well being at the forefront. We are trying to paint a picture of what is going on and what we did. We are showing the nursing process. From a long time nurse.--just my opinion.---

When you say you have seen a supervisors name mentioned in a note, that can be very relevant. I will tell you that in all my years of nursing that if a supervisor was notified of a situation or for an opinion, they don's ask for the chart to write that they were notified or the opinion they gave.

[Sunflowerinsc, ADN, RN]

I hope you are reading notes on a patient that you are assigned . Other wise ,that is another problem, right? Of course with computer charting you couldn't see the notes on a pt that you aren't taking care of on that shift.