ok to use names in charting?

pricklypear · Sep 22, 2005

I don't know how 'right' or 'wrong' it is, but I never do it. No other reason other than I have never found it necessary. For example..."Dr notified regarding no available IV access after multiple attempts by 3 RNs." I've never written "this nurse..." either. I don't see names mentioned it other's charting very often, either, except in regard to supervisors. Like "House Supervisor, M. Smith, RN notified" And I don't even think that's necessary.

lpn1313 · Sep 22, 2005

I was taught never to use the name of a staff member in charting. Using a name opens that person up to legal action if (heaven forbid) something were to happen to that patient.

NHLPN, LPN · Sep 22, 2005

I use initials, if I need to refer to someone or if I've signed something off to another staff member....."Msg forwarded to XY,RN who will be working with MD tomorrow.." "...fall also witnessed by XY,RN..."

NurseforPreggers · Sep 22, 2005

Ok, I find myself on the other end of the spectrum. I ALWAYS use names when appropriate in my charting. As far as opening them up for legal action, so what if it is truthful. For example ... "Telephone report to Dr. Smith re: elevated BPs. No orders received at this time." or "IV started with 18 g stylet x 1 attempt to right FA per M. Smith RN" (if someone other than myself).

If my patient suffers some kind of damage because of an action of a nurse other than myself, I certainly don't want to take the fall for it when it comes to court. What would you say, "someone else started that IV that caused the patient nerve damage, I just don't know who it was, but I swear it wasn't me" ??

pricklypear · Sep 22, 2005

Ok, I find myself on the other end of the spectrum. I ALWAYS use names when appropriate in my charting. As far as opening them up for legal action, so what if it is truthful. For example ... "Telephone report to Dr. Smith re: elevated BPs. No orders received at this time." or "IV started with 18 g stylet x 1 attempt to right FA per M. Smith RN" (if someone other than myself).
If my patient suffers some kind of damage because of an action of a nurse other than myself, I certainly don't want to take the fall for it when it comes to court. What would you say, "someone else started that IV that caused the patient nerve damage, I just don't know who it was, but I swear it wasn't me" ??

I totally understand your point, and have thought about that side of it. But, at least at my institution, (using IV starts as an example) anyone who performs a procedure or gives a med signs off on that chart. So, if the current IV site caused nerve damage, all that needs to be done to find out who started it is look on the IV notes for that patient. Also, that person (at my institution) would (should!) have noted the procedure narratively, also.

Personally, I don't like the idea of my name being put into a patient's chart unless I put it there myself. I guess I'm cynical enough to believe that someone could use my name inappropriately if they wanted to, and that would lead to a whole new chapter if anything went to court. So, anytime I do anything with someone else's patient, I make sure to make a note, or sign off in the appropriate area. Likewise, I make sure that others sign off on my charts.

BTW, using Dr's names is different, IMHO.

lady_jezebel · Sep 22, 2005

We use computerized charting. If we notify an MD for any reason, there is a box we fill out that asks specifically for the name of the doc called & her/his service. I try to always include it, for if there is something going on with my patient, it covers my you-know-what. Sometimes I include their decision to act or NOT act in a quick note -- for example, "hypotensive. pt assessed by Dr.X, no new orders at this time".

This is b/c sometimes docs lie about even being called about problems, unfortunately. I want it documented that I called a specific doc, and that I communicated important data. Charting is for legal reasons, remember. If you ever go to court, you may want a record of notifying the MD (& to give a name, or even "resident of service X", has more credibility). Sometimes I even chart, "notified charge RN X".

I do not chart trivial stuff, such as an IV that could not be inserted. The computerized chart lists the name who puts in the IV, and all the nurses who assess it afterwards; we're not required to write a note about it, we just choose the box regarding why it was d/c'd (ex. "infiltrated", "oozing blood"). I also don't list names when something was done in error. We have alternate routes for pointing out errors, and I don't want to smear someone's name or highlight an issue in the chart that could be a potential lawsuit; for these things we use incident reports, and they're resolved internally.

NurseforPreggers · Sep 22, 2005

I totally understand your point, and have thought about that side of it. But, at least at my institution, (using IV starts as an example) anyone who performs a procedure or gives a med signs off on that chart. So, if the current IV site caused nerve damage, all that needs to be done to find out who started it is look on the IV notes for that patient. Also, that person (at my institution) would (should!) have noted the procedure narratively, also.
Personally, I don't like the idea of my name being put into a patient's chart unless I put it there myself. I guess I'm cynical enough to believe that someone could use my name inappropriately if they wanted to, and that would lead to a whole new chapter if anything went to court. So, anytime I do anything with someone else's patient, I make sure to make a note, or sign off in the appropriate area. Likewise, I make sure that others sign off on my charts.
BTW, using Dr's names is different, IMHO.

If it is noted somewhere else then I agree with you. Where I work in L&D we generally don't have MARs/procedure logs/or paper charting. We chart everything solely on the computer. The only time we even use MARs is if the patient has more than the normal meds or if they are antepartum patients that will be there for an extended amount of time. Alot of times when we have inductions come in in the mornings we will "double team" them. One person will start IV and have consents signed while the other person does computer questions and physical assessment. So there are alot of times where a different nurse may start someone's IV and so forth.

Gompers, BSN, RN · Sep 22, 2005

I usually don't put the nurses names in my charting, like if a nurse started an IV for my baby I just say that an IV was started, period.

I will write the doctor's name, though.

montana912 · Sep 22, 2005

The facility I work in has yearly inservices about documentaion. We were taught in our state ( NY) never to use initials, such as c.t RN witnessed a fall. Write " a staff member witnessed a fall" When I am writing the note, I write, " this writer witnessed a fall". Using initals or proper names can be a legal hassle.

fergus51 · Sep 23, 2005

I write full names when appropriate. I would expect my coworkers to write my full name when I do something for them too.

I do not write "no new orders received" anymore after going to a legal nursing seminar. The speaker said that it is both unecessary (since it's obvious you didn't receive any new orders), and it also sends the message that the nurse felt she should have received new orders but the doctor didn't agree. I now just write Dr X informed of _____.

oldnurse newnurse · Sep 23, 2005

:specs:

We were recently told in a nurses mtg that we should not use the proper names of coworkers in charting. For instance; an ex was made "this nurse,and nurse (so and so, RN) were unable to find suitable veins to start IV... What do you think?? Liswbbrn

Well I attended a seminar for nurses regarding legal issues and we were told to use the name or first initial and last name of a co-worker if the person did something concerning one of your pt.'s because if you were ever called to court charting that the RN did xyandz would not mean anything if at that time in court you can't remeber who that RN was, remeber you can be called for a case 25 years from now what if you have switched jobs wdill you really remember the exact person name and the event accurately?

Always remeber that when you are charting, your charting should be like a story that a person can read and get enough information without having to ask you any questions about what and why someting was done, and that's how I was taught to chart.

Good Luck