signing charts

[lsoconnor]

I recently left a position where I was the only full time RN. One of my former co-workers, an unlicensed individual, was told to by a non-clinical superior to take over the task of signing off on patients' electronic charts. She's obviously not comfortable doing this and I'm trying to get a solid reference/source that states who is qualified to sign patient charts, but coming up short. Can someone point me in the right direction? Thanks in advance!

[MunoRN, RN]

What do you mean by "sign patients charts"?

[lsoconnor]

The chart has to be "signed-off" as complete. Basically, I apply (or did) my signature to all sections of the chart when all sections are accounted for: consents, pre-op, intra-op, PACU, post-op call, etc.

[MunoRN, RN]

The chart has to be "signed-off" as complete. Basically, I apply (or did) my signature to all sections of the chart when all sections are accounted for: consents, pre-op, intra-op, PACU, post-op call, etc.

That sounds like a pretty straightforward administrative duty, I'm not sure why a non-licensed person wouldn't be able to do that.

[lsoconnor]

Thanks for the input. It just seems weird to me that an unlicensed person would be able to close the chart by applying their signature, essentially verifying documentation that may be clinical in nature. But maybe I'm looking at this the wrong way, and it could be considered an administrative task, as you suggested.

[Meriwhen, ASN, BSN, MSN, RN]

What you describe sounds like chart auditing, which doesn't necessarily have to be done by a licensed nurse.

[nurseprnRN, BSN, RN]

Rest easy. This isn't verifying clinical data or passing judgment on clinical documentation. It's just verifying that all the chart sections and components are there and in order for the days of the admission. Any reasonably-trained lay person can do that.