Urgent, Easy Question

  1. Can nurses ever delegate charting? There is a question on this homework I have and our book is STUPID... Well.. the worksheet is too since it all says chapter 16 but it's scattered throughout chapters 25, 34, and some just flat isn't in the book.

    Anyway... Is there ever a situation where a nurse can delegate charting like if they're changing shifts or something? I'm thinking no, but just wanted to be 100% sure.
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    About Mesomorph

    Joined: Oct '06; Posts: 61; Likes: 18

    5 Comments

  3. by   777RNThatsMe
    Quote from Mesomorph
    Can nurses ever delegate charting? There is a question on this homework I have and our book is STUPID... Well.. the worksheet is too since it all says chapter 16 but it's scattered throughout chapters 25, 34, and some just flat isn't in the book.

    Anyway... Is there ever a situation where a nurse can delegate charting like if they're changing shifts or something? I'm thinking no, but just wanted to be 100% sure.

    They can delegate vital signs...sometimes I/Os.... sometimes, even, CBG HOWEVER it is ultimately the RNs responsibility and if they don't get it done...it's the RN license on the line. Delegating other charting for nursing work is not very smart and I have not heard of it being done. Just my 2 cents. It would be highly risky to the license..and may not even be legal. You can look up your nursing scope of practice also. And again it depends on who is doing the charting example... LPN don't "teach" the RN has to do it so then..they could not chart it.... that is in my state anyway. Again... CNA don't assess. So they can't do that. Whatever was being charted would need to be within scope of practice (i.e. CAN = vitals).
  4. by   777RNThatsMe
    Quote from Mesomorph
    Can nurses ever delegate charting? There is a question on this homework I have and our book is STUPID... Well.. the worksheet is too since it all says chapter 16 but it's scattered throughout chapters 25, 34, and some just flat isn't in the book.

    Anyway... Is there ever a situation where a nurse can delegate charting like if they're changing shifts or something? I'm thinking no, but just wanted to be 100% sure.
    And no..you never hand off charting to another nurse for what happened during YOUR shift as they were not there. You never want to do someone elses charting as a nurse unless you did it yourself and thereby its' your own charting.
  5. by   Mesomorph
    Thanks . I'm just going to put "Nurses should not delegate charting." It doesn't directly answer the question... but I'm not even sure this will be graded and I have a careplan to write and another dumb worksheet to do soooo... lol... I'm done.
  6. by   athena55
    Hello.
    Remember that the patient's chart is a legal document. [That is why you are told not to erase an entry or write with those pens that have an eraser on the end]. If your nursing care and all that that care entails is not written or documented in the patient's chart, then it didn't happen (from a legal standpoint)
    Remember "CYA" = Cover Your Arse. Like 777RNThatsMe stated, It is your license on the line.
    If you suddenly remembered something that you did for your patient but forgot to chart it, you can add that data in as long as you document the date, time of this newest addendum.
    athena
  7. by   Daytonite
    repeat after me: if i did it, i chart it. got it? you can't make yourself paranoid about this, but you always have to think about the possiblity of how any documentation you do is going to look and sound if it gets read in a court case as evidence. that is a good guideline in writing and following good practice. in those rare times that i did chart for others the entries were nothing more than to say that, for example, "abdominal dressing was changed by n. nurse, rn" or "n. nurse, rn informed this writer that she notified dr. doctor of the patient's potassium level of 2.0 at 3pm." and then i had better make sure i have more documentation that i followed up on that. the fact is that your nursing notes get read by a lot more people than you would think. since i have been taking classes in health information management (formerly called medical records) i have been astonished at the various people that read over the information in the charts and why they need to see it.

    here's some supplemental reading on documentation for you:
    http://www2.nursingspectrum.com/ce/s...se.html?id=393 - "document it right: a nurse's guide to charting".

    http://www.nursingcenter.com/prodev/...asp?tid=622257 - ladies & gentleman of the jury, i present. . .the nursing documentation. a ce article from nursing 2006 on advice when charting patient care that may help you sidestep a lawsuit or be well prepared to defend yourself in court if you have to.

    https://nursing.advanceweb.com/commo...36532&sid=1095 - documentation. an article from advance for nurses

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