"The only nurse required to sign the OR record is the one taking the patient to the PACU."

[onlyNamerica]

I am a travel RN in the Operating Room / Surgery currently on assignment at a small community hospital that is still using paper charting. I have noticed that whenever I relieve a staff nurse on a case during change of shift, they do not feel obligated to sign the chart. When I asked the OR manager about this, the response was " The only nurse required to sign the chart is the nurse taking the patient to the PACU." In order to protect myself I will chart " Surgery in progress. Report from J. Doe RN @ 1500." I recently relieved on a long bilateral hip replacement and was the 3rd RN relief. I got report, gave the dressings to the field, noted surgery end time and took the patient to the PACU. This was a 3.5 hour long case. I was the only RN to sign the record. What are the implications for this hospital if these charts get audited? Am I held responsible for what the other nurses did because I'm the only one who signed? Comments . . . . .

[Rose_Queen, BSN, MSN, RN]

I don't sign off on things other people document. Back in the days when we were using paper records, every person documenting on it was required to sign it.

[onlyNamerica]

Do you remember the rationale behind every one signing the chart? I am looking for something to show this Manager why everyone should sign, not just the RN who was the last one on the case. Legal, reimbursement, chart audits from CMS etc. I'm trying to gather concrete evidence to present to him, not just my good opinion. I need help ! LOL

[TakeTwoAspirin, MSN, RN, APRN]

So long as everyone who has been present in the room is documented as part of the record (in and out times, etc) I would be OK with it. Even with electronic records, the final nurse taking care of the patient is the one who actually electronically "signs" the chart by being the one that closes it out. While it would be nice if everyone signed a paper chart, as long as there is a record of when they attended to the patient, and presumably in their handwriting what they did to/for the patient, I wouldn't be too hung up on it. I certainly wouldn't complete any documentation in my handwriting that I didn't perform such as positioning, giving medications etc. Also, if narcotics were pulled and administered to the field while I wasn't present, I would make sure that nurse put their initials next to it.

[Rntr]

I would be sure and document what time I relieved on the case ..