Question about signing MAR

KelRN215, BSN, RN · Jan 25, 2012

I, personally, would not sign off a medication that I did not give. I have had similar situations happen to me before and I'll ask in report, "did you give that 6:00 Decadron?" If the answer is yes, the off-going nurse will usually just say "I'll sign it off before I go." If she forgets to before she leaves, I'll confirm with the patient/parent that the medication was given. If they confirm that it was and the medication is still not signed off (we use eMAR), I will usually sign it off as not given and write a comment like "given by day shift per RN and patient report". Katie has no proof that Jennifer actually gave this medication.

caliotter3 · Jan 25, 2012

Agree with previous post. I would not sign off for another nurse, but would make a comment along those lines after confirming with that nurse. The other nurse can fix their own charting. That way no one can accuse me of falsifying the charting of another nurse. I figure I have done enough for the other nurse by making her/him aware that there is a discrepancy. There are some who would immediately run with this info to the supervisor, more concerned with getting someone in trouble than in fixing the problem.

Woodenpug, BSN · Jan 25, 2012

It is document the facts. Respiratory therapy often forgets to chart their meds., I click the box that says "other provider." The thing is was the medication given, if so, I have no problem charting that it was given. If not, or any doubts, I chart that. Then again, if it's something silly like 81mg ASA, I am willing to chart that I gave it. I want information in the chart to be useful to someone else giving care to my patient. The whole, CYA bit is self defeating. We need to chart things that are meaningful to the patients health. The other stuff is a waste of time. I have seen excellent charting, when the nurse was at best slightly less than adequate in her care. It probably, works well in court, but at the cost of her patient's health and / or life. I think it would be so great, if charting was about taking care of the patient and not how will i fare if the powers that be review the chart.

SandraCVRN · Jan 25, 2012

I would write on the MAR "given @ (time) by xyz per xyz"

KelRN215, BSN, RN · Jan 25, 2012

It is document the facts. Respiratory therapy often forgets to chart their meds., I click the box that says "other provider." The thing is was the medication given, if so, I have no problem charting that it was given. If not, or any doubts, I chart that. Then again, if it's something silly like 81mg ASA, I am willing to chart that I gave it. I want information in the chart to be useful to someone else giving care to my patient. The whole, CYA bit is self defeating. We need to chart things that are meaningful to the patients health. The other stuff is a waste of time. I have seen excellent charting, when the nurse was at best slightly less than adequate in her care. It probably, works well in court, but at the cost of her patient's health and / or life. I think it would be so great, if charting was about taking care of the patient and not how will i fare if the powers that be review the chart.

Unless I SAW someone else give the meds, there's no way I'd sign it off for them. (Like, my hospital used to have this weird policy/rumor that only MDs could plant PPDs on patients and most of our residents don't know how to use the eMAR so in that case, I'd sign it off for them because in most cases, I'd be helping them hold the child still for it.) But other than that, no way. Someone telling me they gave it over an hour before I came on shift is not proof. I wouldn't give a medication marked as overdue on the MAR if the off-going nurse and patient/parent confirmed that it was given but, as I said, I certainly would not chart that I gave it and our charting system does not have an "other provider" option.

BluegrassRN · Jan 25, 2012

Our official policy: If someone forgets, and you call them to ask (or they call later), our computer system allows you to sign for someone else. It will read "Given by Nurse Smith on 1/22/12 at 0500, documented by Nurse Jones at 1/22/12 at 0900." There is also a section to write comments, and I typically write something like: I noted med was not signed. Pt states she received med. Nurse Smith contacted, states she did give med."

I won't do this unless the nurse tells me he/she actually gave it. Then I document it for them, but their name is the name that shows up on the record when you check the administration record.

Kashia, ASN, LVN · Jan 25, 2012

Good question, I think we all see missing initials and (gasp) maybe miss signing ourselves.

I personally would not sign for another nurse. It depends on the medication if I would

call the nurse at home. It depends on the medication how critical an error this is and if

warrants to be an "incident" wherein Jen gets thrown under a bus.

just my most humble opinion:-)

MunoRN, RN · Jan 26, 2012

I wouldn't just put down somebody else's initials, but you do need to make sure the chart is corrected, ie chart "Given at ... per Jennifer RN, Katie RN..." It's every Nurse's responsibility to make sure the chart is correct, otherwise the patient could get a double dose, or have the dose adjusted based on the assumption the dose was given. If something were to happen the it wouldn't just be the Nurse that forgot to chart it, if you were aware it was given but didn't clarify that then you're at least partially responsible as well.

AnonRNC · Jan 26, 2012

Our official policy: If someone forgets, and you call them to ask (or they call later), our computer system allows you to sign for someone else. It will read "Given by Nurse Smith on 1/22/12 at 0500, documented by Nurse Jones at 1/22/12 at 0900." There is also a section to write comments, and I typically write something like: I noted med was not signed. Pt states she received med. Nurse Smith contacted, states she did give med."
I won't do this unless the nurse tells me he/she actually gave it. Then I document it for them, but their name is the name that shows up on the record when you check the administration record.

That's exactly what I do.

zorabanks · Jan 26, 2012

I would not chart that another nurse gave a medication, because even if they say they did, you don't know that for sure. In the past when we had paper MAR/TARs, I would flag and leave the nurse a note on the page. Can't chart for another nurse with eMAR. With the system that my facility uses, if it was due on the previous shift, it will not even come up on your shift. So, unless the resident ask about the med, you would not even know that it has been missed. I worked in LTC, so, asking the confused resident was not an option. There have been cases where I have asked an alert person if they received a medication and they did not know. Many times patients don't even know what they are taking. Nursing is a stressfull career. It would help if nurses would stick together and help each, instead of back bitting.

MunoRN, RN · Jan 26, 2012

I would not chart that another nurse gave a medication, because even if they say they did, you don't know that for sure. In the past when we had paper MAR/TARs, I would flag and leave the nurse a note on the page. Can't chart for another nurse with eMAR. With the system that my facility uses, if it was due on the previous shift, it will not even come up on your shift. So, unless the resident ask about the med, you would not even know that it has been missed. I worked in LTC, so, asking the confused resident was not an option. There have been cases where I have asked an alert person if they received a medication and they did not know. Many times patients don't even know what they are taking. Nursing is a stressfull career. It would help if nurses would stick together and help each, instead of back bitting.

You are not charting that you witnessed it was given when you chart that another Nurse reported that it was given, only that another Nurse reported it was given so it makes no difference how "sure" you are about if it was actually given or not.

I've seen many eMars and have to see one where there was absolutely no way to chart something was given by someone else, even if it's a pain to to do it, you still need to make sure it gets charted one way or another to avoid potential harm to the patient. Flagging it so maybe it will get charted tomorrow doesn't count.