ok to use names in charting?

Nurses General Nursing

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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

Specializes in NICU, PICU, educator.

Our legal department has advised us to document proper names, better yet, if someone does something for you then they document it themselves. Their point being, if so and so puts in an IV and it is in an artery and the kid's arm falls off tonight, then who was responsible for putting it in? Gee, you didn't say it was Will Smith, so it must have been you, therefore you are in deep doo-doo. Another example....you go to lunch and Nervous Nell has suctioned your kid and the kid is now pulmonary bleeding all over...do you think I am going to let it be thought that I suctioned Jr? No way, Nervous Nell is gonna take this one.

Wow. This is an interesting discussion. I am currently taking my pre-req's to go back to school for nursing (am on waitlist.) I'm going from detailed oriented accounting/secretarial jobs all my life to nursing. It's neat to see people's views on this, because I am a worry-wart, and always afraid of forgetting a detail, and getting punished for it. I'll have to see what I am taught, but believe me, from what I have seen in the "real world" you need to look out for #1, because no one else will. I have a feeling, just knowing myself, that I would be more detailed, rather than less detailed. Not that I would be the type of worker to just get others in trouble, but if someone messed up, and I had to appear in court for it, I would DEFINITELY want MY ducks in a row.

Specializes in Education, FP, LNC, Forensics, ED, OB.
:specs:

....... we were told to use the name or first initial and last name of a co-worker ........

This exactly what the defendant attorney will want to see in the medical record. :)

This exactly what the defendant attorney will want to see in the medical record. :)

Then what would you recommend, Siri?

Specializes in Medical.

I'm not particularly worried about legal liability, probably because Australia isn't as litigious as the US - at least for now.

I always write the doctors' details (eg "BP at 2400 195/95; covering RMO J. Brown [bp 1234] contacted - recheck in 30'"), primarily to cover myself, having been badly burned once before by a doctor who denied having been contacted.

As for fellow nurses, it depends on the circumstances. I say that even though I can't remember an occasion where that would be necessary. Although I'd put specifics (like who saw a patient fall) on the incident report, I think I only write something like "witnessed fall" in the notes.

This is a really interesting thread :)

Specializes in Education, FP, LNC, Forensics, ED, OB.
Then what would you recommend, Siri?

Hi, BabyRNTess,:balloons:

I knew when I submitted my reply that it could possibly be misinterrpreted. But, I did it anyway. Sorry. I will clarify.

The defendant is the institution and you (the nurse). The defendant attorney will want to see that you charted appropriately. In other words, if you are under scrutiny, the plaintiff attorney is looking for the fact that this (name of the actual offender) was left out of the medical record, therefore you must have committed the act and no one else.

Entering the first initial/name and the last name with credentials is appropriate.:)

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