students charting Assessments

NurseKatie08, MSN · Mar 13, 2016

Why shouldn't they? My students chart on their patients in Epic and I am able to cosign their work/notes. I see it as an important tool for their learning.

RescueNinjaKy · Mar 13, 2016

I have no issues with students charting their assessments. If the hospital has granted them that access and privilege then go ahead. But as a nurse who he student is following, I am going to review their assessment and write a note that I have reviewed their assessment and that I either agree or if there are variances based on my own assessment.

Vishwamitr · Mar 14, 2016

Yes. Unfortunately, you are the only one. You are starting off on a wrong foot. I am not sure if nursing is for you.

AspiringNurseMW · Mar 14, 2016

Am I the only one against students charting assessments in the patients chart ?

Student here. Can you tell us why? It is expected of us to chart assessments (except LTC, OB, and Psych) . Assessing a patient and subsequently charting that assessment is a MAJOR portion of a nurses job is it not?

Our charting did not preclude the nurse from charting her own assessment, and in my most recent clinical rotation our clinical instructor would review our charting after submitting it.

What other option would there be?

PCnurse88 · Mar 14, 2016

As someone whose clinicals in school NEVER included charting on patients in any sort of EMR, I feel confident when I say that it is hurting students not to do so. As a nursing student I had no access to any sort of computer charting and very limited access to anything on paper. When I was hired onto my first floor as a new grad I had no idea what to do. Granted, an assessment is an assessment - but I had never written a note, or learned the "charting by exception" method that so many servers use. It was a major hindrance. I was fortunate enough to be computer savvy; some of my classmates weren't, and really struggled.

akulahawkRN, ADN, RN, EMT-P · Mar 14, 2016

As long as there's someone able to counter-sign the student's charting, I have no issue with letting students make entries to a patient's chart. If I had a student, I'd check their charting and also do my own assessments because I'm the one responsible for the patient. If I agree with the student's charting, I counter-sign their charting and then I'm also held responsible for those entries because I'm agreeing, as a licensed person, that the charting done was accurate.

If someone is reviewing the charting with the student as the entries are made, that's an opportunity to teach proper charting as well. My charting is a blend of styles that work for me. I follow the notion that if it wasn't charted, it wasn't done, even if it's a CBE system. My ED uses CBE. If everything is "normal" in a CBE system, there wouldn't be anything to chart! So what I do is I go into detail in the things that need to be charted and "WDL" everything else because that's at least an indication that I have "touched" on that system and it's not abnormal.

If I hadn't been allowed to do any charting as a student, I would have really been at a loss because I wouldn't have known what, or even how, to do the proper entries into the computer or into the patient's paper chart during my psych rotation. We did have much more personal attention when writing in the patient's chart... and the instructor always counter-signed the charting, noting where she agreed or disagreed with our charting.

canigraduate · Mar 14, 2016

No problem for me at all. As a clinical instructor, let me tell you, students really need to be taught to chart. Using the real world system versus a paper flowsheet made up by the school gives the student a chance to learn it right. That makes for that much less for you to correct when you're precepting a new grad.

Here.I.Stand, BSN, RN · Mar 14, 2016

Why not? They're clearly signed as Their Name, SN ... it's not like they're charting under your login info. My unit doesn't have many students, but I see medical students' notes in the cart all the time. Why shouldn't nursing students learn to chart?

Julius Seizure · Mar 14, 2016

Med students document notes in the computer, do they not?

la_chica_suerte85, BSN, RN · Mar 14, 2016

Student here: No, it's weird and I don't like it when my precepting nurse asks me if I can do it. I'm not supposed to and I get put in the precarious position of having to decline the task much to the frequent annoyance of my preceptor. It's not that I don't want to, it's that I should not be doing it. It doesn't mean I don't want to insert a foley or spike a bag and prime a line for them.

la_chica_suerte85, BSN, RN · Mar 14, 2016

Why not? They're clearly signed as Their Name, SN ... it's not like they're charting under your login info. My unit doesn't have many students, but I see medical students' notes in the cart all the time. Why shouldn't nursing students learn to chart?

I'm fine with charting vitals and the stuff I did under the preceptor's supervision. I am not cool with charting an admission assessment, especially when I'm not the one who did it in the first place. This has happened to me on a regular basis.

By the way, I say that as someone who has a job as a nursing assistant and I hang out while the nurses do their admission assessments so I have a good idea of what to do from that end.