using names when charting

djsrn · Dec 18, 2004

Hi,

Quick question; when you all chart, do you put a name to a person?

Example: Bob, nursing assistant, placed foley. Or do you just chart nursing assistant placed foley?

I was taught not to chart the actual person's name in the chart. Also, does anyone know of any professional websites on legal issues related to charting? thanks in advance!

Mandee · Dec 18, 2004

I always put the persons name myself.

Mandee

Hi,
Quick question; when you all chart, do you put a name to a person?
Example: Bob, nursing assistant, placed foley. Or do you just chart nursing assistant placed foley?
I was taught not to chart the actual person's name in the chart. Also, does anyone know of any professional websites on legal issues related to charting? thanks in advance!

Mandee · Dec 18, 2004

I always put the persons name myself.

Mandee

Hi,
Quick question; when you all chart, do you put a name to a person?
Example: Bob, nursing assistant, placed foley. Or do you just chart nursing assistant placed foley?
I was taught not to chart the actual person's name in the chart. Also, does anyone know of any professional websites on legal issues related to charting? thanks in advance!

TracyB,RN, RN · Dec 18, 2004

hmmm, good question... Think I will do a search for a site on charting.

I am sure each state has some different twists to their charting requirements.

Personally, I have used things, like "charting nurse inserted 16 fr foley catheter without difficulty & return of 100cc cloudy, yellow urine."

TracyB,RN, RN · Dec 18, 2004

hmmm, good question... Think I will do a search for a site on charting.

I am sure each state has some different twists to their charting requirements.

Personally, I have used things, like "charting nurse inserted 16 fr foley catheter without difficulty & return of 100cc cloudy, yellow urine."

fergus51 · Dec 18, 2004

I put the actual person's name. If this ever goes to court how are they going to know who did what if there were 5 nursing assistants on duty?

fergus51 · Dec 18, 2004

I put the actual person's name. If this ever goes to court how are they going to know who did what if there were 5 nursing assistants on duty?

live4today, RN · Dec 18, 2004

Sometimes I have put names of staff in my charting, and sometimes not. Depends on what I'm charting about. :nurse:

live4today, RN · Dec 18, 2004

Sometimes I have put names of staff in my charting, and sometimes not. Depends on what I'm charting about. :nurse:

meownsmile, BSN, RN · Dec 18, 2004

I only use names when something was reported to me by another staff. There is no need for me to chart who inserted a foley if they have done their own work and charted the foley insertion in the first place. If they havent charted it I will remind them and have them chart their own procedure. I only need to chart that the foley is in place and patent (with drainage discription) at this time.

I might chart elevated temp reported by (last name and title only) and reported to dr by phone (with or without) new orders recieved.

meownsmile, BSN, RN · Dec 18, 2004

I only use names when something was reported to me by another staff. There is no need for me to chart who inserted a foley if they have done their own work and charted the foley insertion in the first place. If they havent charted it I will remind them and have them chart their own procedure. I only need to chart that the foley is in place and patent (with drainage discription) at this time.

I might chart elevated temp reported by (last name and title only) and reported to dr by phone (with or without) new orders recieved.