Student nurses and legalities of online charting

[darksideRN]

I am a nurse in a small Oregon town hospital. We have recently started changing over to electronic charting and medication administration. Does anyone out there have any policies relating to student nurses in their facility and how to monitor their activity and charting. We are really struggling here to develop one and if anyone could help us to not reinvent the wheel, it would be appreciated.

[tookalongtime]

All of the hospitals that I have done clinicals at require us to have an S in front of our login to indicate that we are students. They can easily track each individual's charting. Our clinical instructor also is responsible for checking our charting throughout the day and she lets us know if it needs correcting or not.

[BabyLady, BSN, RN]

At the hospital where we do clinicals they have already made the change to electronic charting.

We chart very, very little, mainly because we simply cannot be proficient at it working only 1 day per week in clinical and we receive no computer training, while employees get 3 full days.

They do give us a list of where to chart so we follow it.

When we are done, it is required to have the clinical instructor review the charting, double check anything that was missed, and then there is a "comments" section at the end where it's charted as:

Jane Doe, SN

As reviewed by Minnie Mouse, RN

That way, they know who checked behind the student.

[NurseLoveJoy88, ASN, RN]

I'm a student nurse and we must complete a 4 hour charting seminar at each facility where there is online charting. We sign in as nursing students and our instructor signs off behind us. Nurses are also able to access our charting. I'm currently at a facility where they don't let us chart assessments, we can just sign off on meds and vitals and some other small things. However, I've been at other facilites where students were allowed to chart assessments. Please check with your nursing supervisor because each facility is different in what they let students chart.

On another note, thanks for being patient with us nursing students !

[mjjlRN]

As an RN at my facilty, I am currently precepting a senior BSN student. She went through the charting class, and she charts everything (Except the Plan of Care) just as a nurse would. Then, I go behind her, read all her charting, and must co-sign everything (There is a special tab to click on to co-sign in our system). When I co-sign, I have the choise of agreeing with or modifying the student's assessment. Because I am precepting the student, I do not have to chart my own assessment, I simply co-sign hers. However, when have students with their instructor on the unit doing their clinicals, they chart, their instructor co-signs and checks their work, and I chart my own assessment as well.

[Sarah Hay]

When we chart electronically on the computer, we are required to 'save' everything except the vital signs and medication administration in order for the tech or nurse to finish the ADLs because we are not there for supper time so we are not able to input the percentage eaten of supper. Also, our instructor 'OKs' everything we submit before it is final. I hope this helps.

:redpinkhe Sarah Hay, SN