Students not charting...If it isn't charted..who did it?

[nurz2be]

I am a student in FL. I have been thinking about something recently and was curious if you could help me come to a conclusion.

We, as students, are not allowed to "chart" in patient medical records, at the LTC facility we are at.

We have a person who, since us beginning at that facility, has taken a serious turn for the worse. Now, no one is blaming students or anything like that but where my thought lies is, as a nurse, if you don't chart it--it did not get done, correct? In Florida, I don't know about other states, students are held responsible for their actions, that is why I have NSO coverage.

So, my question is, if students are not allowed to chart their activities with a patient, and something comes up in the future, what is to protect that student from litigation or worse losing their license?

I was thinking of proposing something to my school regarding a chart system kept at our school, I just don't know what ramifications that might have.

We were told that when we get along further in the "program" we will be charting but for now, there is nothing to "CYA."

I posted this to a staff member who thought this is a good "Group think."

Anyone have any feedback to assist me in my next move with my school and its, or the LTC facilities policy on students charting?

THANKS!!!!!

[AprilRNhere]

Is there another nurse following behind you? When we were first semester students in LTC we did not chart either (except for meds)...BUT- the reasoning behind it was that it didn't really matter. They don't do full physical assessments on residents every day- so what we were doing was "extra" and the nurse is still responsible for the pt. If you notice anything off..you should report it to the resident's nurse-since they are responsible.

[nightmare, RN]

Can't the students chart and be countersigned by the mentor?

[casi, ASN, RN]

Since LTC patients were considered stable, we didn't chart either. It had something to do with the way the facility got reimbursed. We reported any abnormals to the nurse responsible for that patient.

[MikeyJ, RN]

We have charted from day 1 of clinicals, and our instructor or nurse co-signs. The only clinical we do not chart in is our psych clinical.

[Blee O'Myacin, BSN, RN]

We didn't chart when we did our LTC rotation either, unless we were giving meds. Then we signed with our instructor cosigning. All of our paperwork had to be signed by an RN - whether it was our instructor or the patient's primary nurse because since we were not licenced.

If I have a student pass meds, I am right there and I co-sign (although when students are with me in the ER, it is strictly observational, so they don't give meds.). But on the floor, it is expected for the student to chart the assessment, a note, sign out meds and have the instructor cosign all of it.

Blee

[ecnav]

student nurses are not 'legally' responsible. they have no license or permit. students operate under premise that a licensed professional is guiding, assessing, and validating. the clinical instructor is ultimately responsible. if student charting is permitted, the clinical instructor should countersign, otherwise, whatever's being charted isn't valid. this is why i refuse student assignments. yet, i really enjoy working with students - it's a real pleasure. nevertheless, i'm compelled to reject the privilege of working with students for the sake of protecting my license.

:typing

[ecnav]

We have charted from day 1 of clinicals, and our instructor or nurse co-signs. The only clinical we do not chart in is our psych clinical.

Excellent. Must be a good program.

[Ms Kylee]

We chart... and sign our name with SPN and our school after it. Then our instructor signs underneath our signature.

[Antikigirl, ASN, RN]

Sorry...but I feel the same as the OP. I will chart what I found, did, and everything...and if the facility chooses not to put it as a perm part of the chart fine...but that is a lawsuit in the makes!

If a facility lets me render ANY care of another human being in their liablity...then they BETTER expect me to document what I did for the record. Not only does that protect them...but me as well...so I don't get some lawsuit or trouble when someone says "oh the student must have done it".

I would be talking to my college supervisors about it...and sorry, but yes I would make waves to the BON as well...since that can't be their stance on it!!!!!!

Smart question!!!!!!! And remember...ALWAYS document, and know where to keep those documents (can't take them home...most places can't take them out of there...so you need guidance as to where to keep them for record!!!!). And if they won't let you...honey, you really need to either stand up, or decline that clinical...it is up to your choice according to situation. The college should stand up for their students...if they aren't...ummmmmm what are you spending money on again????

[Penelope_Pitstop, BSN, RN]

we chart... and sign our name with spn and our school after it. then our instructor signs underneath our signature.

that's what we did also, kylee. i signed "university of delaware student nurse" after every note i wrote, and "udsn" on the mars and flow sheets. also, some of our instructors weren't big on us writing notes, but for my first hospital rotation, i wrote several notes. i don't remember writing notes in every rotation, but i do know i charted on mars and flowsheet (except for psych, community health, and older adult assessment).

as for whether it's "necessary," i don't think that matters! nurses who are able to write effective notes will benefit in the long run, and how can we learn to write notes if we don't start immediately? i know that in ltc, maybe there aren't full assessments written in the progress record on a daily basis, but how often are any kind of notes written? are there progression of care, or just note writing by exception? and in other settings, such as the floor, even if the student nurse's note brings nothing new to the medical record, who cares? i've always charted after the students because of time issues (they left before my shift ended, and had less patients, that kind of thing) and i don't care if my assessment on the flowsheet is identical, i want evidence of my assessment charted. if there is a note written and i feel as if i do not need to add anything, i will still write something so that a nurse has written a progress note that day.

that was much much longer than i intended.

long winded as usual,

jess

[nurz2be]

I appreciate all of your comments so far. I am in FL, and the state nurse practice acts DO say that students are responsible for delivering the same care as the nurse who is in charge of that patient, sort of an oxymoron saying students care is = RN care.

We had a legal class last week and it was clearly stated that "students do not "ride" on anyones license." Yes the instructor is "responsible" to a point but the instructors license will not come under fire, in most instances, if something goes wrong. (This is the information presented to us by our instructor and a lawyer who specializes in appearing in front of the FBON). If I, a student, "harm" someone it falls under the facility, the school, and ultimately myself. We were told this is why "most" schools either insist upon or highly recommend nursing students to get malpractice insurance. As I personally have sought out doing through NSO.

Anyway, I am really seeing the reality of not having anything charted. Yes, when there are issues we write a "note" for the nurse in charge of that patient. If it is something of great concern we always go to our instructor.

As far as is anyone coming behind us except for our instructor and the nurse only passing meds, we don't see a soul the whole time we are there. We do dressing changes, Foley's if need be, meal assistance, bathing assistance, turning, and whatever else that patient needs for the time we are there, except for meds.

Call me paranoid but I do not want anything to jeopardize my future as a nurse, nor do I want anyone else to have to answer for something that our school does not deem a "priorty." I mean seriously, we have nearly 12 nursing instructors and no one has had an ah hah moment. I am glad nothing "serious" has gone wrong but just because it hasn't does not mean that it won't, right??