is it ok if i write on somebody else's nursing notes and then she/he would sign it?

Specialties Geriatric

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wooh, BSN, RN

1 Article; 4,383 Posts

My concern is, "why do you have to write the same thing twice?" As apparently she's written it in one place that it needs to be written, then you're copying it to the chart. Writing it twice just seems silly. (But I know how facilities like for us to write things as many times as possible.)

Penguin67

282 Posts

If you did not do it, see it, assess it or talk about it, you should not ever chart it. The previous posters are right, a lawyer in court would have a field day with that type of charting.

Also agree with one of the posters who suggested helping your coworker to become better with time management and charting.

As Stephen Covey says "If you aren't part of the solution, you are part of the problem."

Specializes in Emergency.

As Stephen Covey says "If you aren't part of the solution, you are part of the problem."

Covey actually meant "If you aren't part of the solution, there's good money to be made in prolonging the problem". The mantra of consultants the world over.

OP, agree with above posts. If your friend wrote it once legibly, she/he can chart it themself.

Sparrowhawk

664 Posts

Specializes in LTC.

Don't do it again.

sjoy

54 Posts

Specializes in Dialysis, Home health.
If you did not do it, see it, assess it or talk about it, you should not ever chart it. The previous posters are right, a lawyer in court would have a field day with that type of charting.

Also agree with one of the posters who suggested helping your coworker to become better with time management and charting.

As Stephen Covey says "If you aren't part of the solution, you are part of the problem."

If you didn't do it, see it, or hear it....you cannot write it. Plain & simple. Don't complicate the matter. There is no excuse. Don't get her or yourself in trouble, because when you least expect it it may cause you to lose your job..or license.:down:

tewdles, RN

3,156 Posts

Specializes in PICU, NICU, L&D, Public Health, Hospice.
i dont see were the legal issue is here......your name/signature is not on the note, hers is.....basically your are transcribing for her......if this goes to court she is the one being called, not you.....

She is the one going to court...until she says "but I didn't write this...", then you will be going to court also. At that point you are both in hot water and will have to explain first what actually happened with the patient and who actually provided the nursing care and second why either of you would participate in something we learn about in nursing 101.

Separately, you will have to explain why you wrote a note on a patient you did not see and why she signed a note she did not write, as well as the difficulty of explaining why you wrote what you wrote (those report notes will be LONG GONE and there will be no evidence that you had any written info at all). I seriously doubt that there is a company policy which allows one professional to transcribe for another professional. In this case, the documentation is not even clearly identified as a transcribed note...it simply appears as a note written by the author, even tho it is not. Trust me, no employer would be happy with this type of nursing practice...

Specializes in LTC, Acute Care.
i dont see were the legal issue is here......your name/signature is not on the note, hers is.....basically your are transcribing for her......if this goes to court she is the one being called, not you.....

If writing (typing in my case) a note for someone is illegal, I'd have no job!! There is always a place for the dictator to sign, plus my unique initials are on all my documents so I am identifiable as the transcriptionist, too. OP, if what you are doing is okay, I think you'd have to make yourself conspicuously identifiable on the note. It is terribly exceedingly rare, but even though the signer is responsible for the content of the note, the transcriptionist can be found liable for certain errors. Just so you know...

Specializes in LTC, Acute Care.
Trust me, no employer would be happy with this type of nursing practice...

I've done transcription many times for clinic RNs.

Specializes in LTC, Acute Care.
Oh GOD! what can we do from here then?

Ask your employer, but I would think "transcribed by penny1987" with the note would help.

Jolie, BSN

6,375 Posts

Specializes in Maternal - Child Health.

Under extreme situations in our NICU, we would occasionally have the treating nurse dictate to a transcribing nurse as the care was being given, so that a complete and accurate record was immediately available, and no one had to go back after the fact and try to remember vitals, meds, treatments, etc. and document them accurately.

These entires were always noted, "Written by Jolie, RN as dictated by Jane, RN, and both nurses would sign.

They were not considered improper, and never questioned, to my knowledge.

But the difference was that they were necessary due to extreme situations, and not a routine charting method to help a co-worker finish on time. I think your employer needs to examine staffing, experience, work habits and work load if this is the only way nurses can finish their assignments in a reasonable time frame.

nicole109

147 Posts

I agree with Jolie--in extreme circumstances, ie: a code situation, we would have 1 nurse that was recording information, and he/she was often at the door of the room, unable to really see everything that was going on; but would write everything that was shouted out, and that he/she would write or type the note for the nurse who was actually caring for the patient that coded, or they would write the note together, bc often times the recorders note was very difficult to decipher afterwards, but then both nurses would sign the note. This wasn't something that happened routinely though...

If your friend is having trouble getting everything done, and your notes that you are writing for her and just "double charting" anyways--then perhaps a short note that references what is charted in the shift assessment flow sheet is acceptable. At the facility that I came from, we only charted by exception, so our narrative notes were only a couple of sentences unless something outstanding happened during our shift, and normally said something like "patient x Alert and oriented, vitals stable, see meditech for full assessment." Because our meditech (computer charting) was SO detailed and we charted q4 hour assessments, it covered everything else, no need to double document, such a waste of time...

nurse grace RN, BSN

1 Article; 118 Posts

Specializes in med/surg, TELE,CM, clinica[ documentation.

I believe that the fact that you asked on this forum made you suspect that what you did was not a good idea. I remember very clearly from 1st semester nursing school-- it was drummed into our heads- "NEVER EVER chart anything, you did not, do , see, hear,etc. except for certain emergent situations. Your friend is , your friend now, you don't know what could happen in the future-- you could be left holding the back and then -- you have made false statements on a medical chart and a lawyer will have a great time with that. I would not do it ever again, I would offer ways to help your friend be more able to get her own charting done. Also, I would be very careful about info you divulge, even on a forum such as this because you do not know who is on as a guest and just looking for info to use against people. I think you will be more aware in the future of the implications of charting--sometimes we just do things to help one another but be more careful--even co-signing in a pyxis or other medication cabinet can come back to haunt you. :twocents:

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