students charting Assessments

akulahawkRN, ADN, RN, EMT-P · 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.

If your school says you may not make entries to a patient's chart beyond basic vitals and the tasks you have completed under supervision, then you're on solid ground to refuse to do charting beyond that scope.

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.

To me, this sounds like you're kind of in CNA mode. If your preceptor did an admissions assessment and you didn't, then you do not chart their findings. We're in agreement with that. I don't chart another nurse's assessment, though I will (and have) charted another nurse doing a specific task that I am aware was completed. The task is attributed (always) to that other nurse. That being said, if you do any assessments at all, it is up to you to chart your findings. I have charted full head-to-toe assessments, including skin assessment, as a student that were countersigned by my preceptor or my instructor, after they've done their assessments. After I do my assessment, I would eventually look back at the chart and I would always see an assessment entered by my preceptor. Always. While she came to trust my assessments, she was the hospital employee and therefore was required to do her own and this also allowed her to check my charting.

AspiringNurseMW · Mar 15, 2016

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.

Well this discussion isn't about charting FOR a nurse, it's about charting YOUR assessments as a student and any procedures you may have done. If I do a head to toe assessment on my patient, then that's getting charted. At first for the first week in the hospital setting, we only charted vital signs. Then, every week, my instructor would would add 2 or 3 new body systems to chart on. By week 5, we were charting pretty much everything we did, everything signed, SN.

When we moved to a hospital with Epic, the system automatically notes that we are students, and if we entered any notes, the system had a template for student nurses that we had to use.

Regardless, even as a nurse, you are not supposed to chart something you didn't do.

RescueNinjaKy · Mar 15, 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.

Part of precepting is teaching how to use the charting system. If the school doesn't allow the student to do so then that's fine, I'm not gonna tell the student to do so if it's not allowed by their school. Now if their school allows them to, which many do, then there's no issue with them charting their assessment as long as I review and sign off on it after doing my own assessment.

RescueNinjaKy · Mar 15, 2016

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.

This is a completely different situation. If you're a cna in the room and a nurse is doing the admission assessment you shouldn't be charting it. Lpns can't do initial/admission assessments in most places let alone a cna. Whoever the nurse is that's telling you to chart for them needs to do it themselves and be aware of scope of practice, veracity and integrity. Ain't nobody got time to chart your assessment for you.

Now even a student should not be charting for anyone else. If you're in the capacity of a student and your facility allows you to chart, then you chart what YOU assessed. The primary nurse needs to do their own assessment and then sign off on your assessment as to whether they agree or have any discrepancies.

BSNbeauty, BSN, RN · Mar 17, 2016

Thanks for the responses. You all are correct. I just need to ajust my attitude about students charting. I think it was stressful for me to have to make sure all the charting is correct and accurate.

canigraduate · Mar 17, 2016

Thanks for the responses. You all are correct. I just need to ajust my attitude about students charting. I think it was stressful for me to have to make sure all the charting is correct and accurate.

That's the CI's job, not yours, unless you are precepting. You can take it upon yourself to notifiy the CI if you think the student's charting is stellar, or needs correction, but it isn't part of your duties.

mosaicism105, MSN · Mar 17, 2016

I always do head to toe assessments with my students and let them chart the assessments in EPIC. We are allowed to chart and will utilize the opportunity for learning.

toomanypants · Mar 18, 2016

I rarely enjoyed being a student nurse, because it's so hard to feel like you are doing anything significant.

But then I was assigned to a nurse on a neuro telemetry floor for three clinical days. He let me chart a full assessment in Epic, which meant that I actually had to do the full assessment on the patient. It's easy to half-butt an assessment when that information doesn't go beyond your own brain. I was able to feel accountable for my judgment and assessment skills, and it made me much more attentive. He also let me chart the meds, vitals, and all other interventions. I was busy and loved it. It brought me closer to my patient, I believe, and provided me with one of the most emotional experiences I had as a student.

walkingdeadhead · Mar 24, 2016

Our facility banned the students from charting a few years ago because it did not always match the nurse's charting...usually the students was more accurate but I'm sure they saw a potential lawsuit. Now our students have no computer access unless I'm there to login. Our school bought Simchart from elsevier for our students to practice electronic charting. The only hassle is getting the patient information loaded in.

vintagemother, BSN, CNA, LVN, RN · Mar 24, 2016

Re: walkingdeadhead:

Simchart sounds awesome! I wish we had it.

As an LVN/PN and now RN student, charting really scares me.

When I worked, we were training on the electronic charting system in depth.

We also received clear instruction from our admin on what to chart and with what frequency.

However, in school, each CI has had differing expectations and the expectations of each different floor of the hospital are different. From what I can tell, each nurse does it differently, also. I think some differences are based on the pts dx.

I so wish I knew the best/gold standard in charting.

I digress.

Lame · Mar 27, 2016

This is a completely different situation. If you're a cna in the room and a nurse is doing the admission assessment you shouldn't be charting it. Lpns can't do initial/admission assessments in most places let alone a cna. Whoever the nurse is that's telling you to chart for them needs to do it themselves and be aware of scope of practice, veracity and integrity. Ain't nobody got time to chart your assessment for you.
Now even a student should not be charting for anyone else. If you're in the capacity of a student and your facility allows you to chart, then you chart what YOU assessed. The primary nurse needs to do their own assessment and then sign off on your assessment as to whether they agree or have any discrepancies.

I think in most places with computer charting, CNAs don't even have the option of charting things outside of their scope.

RescueNinjaKy · Mar 28, 2016

I think in most places with computer charting, CNAs don't even have the option of charting things outside of their scope.

It sounds more like the nurse is having a cna chart under their login. Kind of like a dictation. Which is all sorts of wrong.