Question for you.

PegRNBSN · Jun 28, 2007

I always do my own assessments. There are some nurses on my unit who, when admitting a patient, will take the medical student or residents assessment and then chart their findings.

I do my own for two reasons.

1. I only chart what I do myself. Part of my nursing role is to assess the patient.

I may not agree with the medical provider's assessment.

2. Even if everything is normal, if something should change later in my shift, I need to know what the baseline was.

I would explain it to the parents that I need to asses for myself so I am familiar with their baby. You can also use your assessment as a teaching moment to help them become familiar with their baby.

rn/writer, RN · Jun 28, 2007

I always do my own assessments. There are some nurses on my unit who, when admitting a patient, will take the medical student or residents assessment and then chart their findings.
I do my own for two reasons.
1. I only chart what I do myself. Part of my nursing role is to assess the patient.
I may not agree with the medical provider's assessment.
2. Even if everything is normal, if something should change later in my shift, I need to know what the baseline was.
I would explain it to the parents that I need to asses for myself so I am familiar with their baby. You can also use your assessment as a teaching moment to help them become familiar with their baby.

Thanks, PegRNBSN, for saving me the trouble of typing out the exact same thoughts.

Your assessment is done so that you have hands-on familiarity with the baby. That way, you can chart what you have seen and heard.

Think of it like a court of law. Anything someone else assesses is "hearsay."

Besides, with med students and residents, depending on their level of experience, you may very well catch something they didn't.

Elvish, BSN, DNP, RN, NP · Jun 28, 2007

Many many times I have found something that someone else missed (MD, nurse, med student, whoever). The shoe has sometimes been on the other foot as well. It's really important to know what's going on with that baby that moment, should something change, like has been posted already.

We have to do VS every shift anyway. While you're doing that, you might as well go ahead and assess the baby. Not a great big burden, IMO. I like Peg's explanation -- you're assessing so that you are familiar with their baby, and invite them to see what you're looking at.

babydoll99_99 · Jun 28, 2007

Thanks for all your feedback. I feel better knowing that I am not doing something that is unnecessary. I work 12s so we end up doing 2 VS and assessments on each shift. Thanks for the tip on incorporating the parents into the assessment. Great idea!

Thanks again

passionate · Jul 2, 2007

Your own assessment is never unnecessary and don't ever be bullied into thinking that is wrong.

KYCNM · Jul 5, 2007

I'm surprised you weren't taught in your program to incorporate the parents into the assessment experience. I have my students do this (though most do it with trepidation [what if I can't answer the parent's questions?]). I tell them that the sign of an educated person is not that they can answer all the questions, but that they know where they can go to find answers.

caliotter3 · Jul 5, 2007

Imagine you are giving a deposition or testifying in a courtroom, and you are asked about your assessment of the patient. How is it going to look when you state that your charting really mirrors the assessment done by somebody else, even if it was the doctor? Always, always do your own assessments.