using names when charting

winterblue · Dec 22, 2004

Recently attended a legal nursing seminar. Was taught to always use names. Also, it is appropriate to use personal pronouns in charting when describing your own actions, I didn't know that before.

BTW, the stories told in that seminar were a bit scary! Physicians who had tried to go back days later and make a late entry; proven after the note was analyzed by a handwriting specialist.

SmilingBluEyes · Dec 22, 2004

Yes, I do use names where appropriate. I think, legally, it is a must.

nurseyd · Dec 22, 2004

I recently worked in a facility where we did "team" nursing, and the concept was really taken too far- people would chart anything as though they did it even if the procedure was done by someone else.... so in that situation if I was writing a note on a pt I would document IV started by D. Smith, RN, etc. etc. hoping that by example they would realize you need to be responsible for your practice even though we were a team.

been there · Dec 22, 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!

For your legal protection it's always safest to put the name and title of the person who actually performed a technique on your patient on your chart documentation. Be direct, clear,and never vague, in charting. If a nursing assistant placed a foley is there documentation in his personnel file that he is qualified to do this? I wasn't aware that CNAs could do more than basic cath care. Maybe in your state? And now there is controversy about CNAs allowed to pass med? God help us and the patients.

graysonret · Dec 22, 2004

I've always used the name of the person in my charting. I want no confusion in the future, in case a question is raised...especially since I am an agency nurse.

Retired Nurse · Dec 24, 2004

Yes, chart the names if it is something you may need to remember. CYA

DutchgirlRN, ASN, RN · Dec 24, 2004

If someone placed a foley for me (if I am tied up in an emergency or whatever), I chart the person's first name, last name and credentials. Or sometimes I will use the first initial of their first name along with their last name.

That's exactly what we are required to do. It's like another member said: If it ever goes to court and there were 5 techs working how would they know which one inserted the foley? Granted routine procedures rarely get hauled into court but hey in a sue happy society why take the chance?

chad75 · Dec 24, 2004

Well currently I'm an LPN, and if I receive a directive from, report a condition to or consult with an RN I use their name. I.E. Reported to J. Doe RN that patient continues to be in uncontrolled a. fib one hour after administration of po cardizem. She directed me to notify Dr. Heartsalot, Physcian contacted and received orders for a cardizem drip etc. etc.

As you well know if things go south J. Doe RN might say I never reported the patients condition to her and being an LPN you work under the supervision of an RN according to the LPN scope of practice (I knew before consulting with the RN that we needed to get an order for a cardizem drip, but its all about CYA). This way I have a written record of the time and person I consulted with.

Mistorri · Dec 24, 2004

Well, some places insist that you do not use names, while others encourage it. So you need to ask the Supervisor for the policy at your place of employment.

I know that if there is something that I need to chart like: reported c/o pain to S. Doe, RN, Charge Nurse, I will do so. Especially if that is what I was told to do by a Supervisor. Report it to her and let her handle it. I have seen my name charted on in this fashion many times. You expect it if you are in charge.

lovis · Dec 27, 2004

undefined

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!

ok, here's a try; im from sweden..and here you have to sign your initials at the end of your statement since you are responsible for writing it down. don't think that'll help you since i'm sure you have different recommendations than us and from state to state as well.

good luck! /g.

Cubby · Dec 27, 2004

Just remember, this is your chart as well. If you are sitting in front of a judge and jury ten years from now - you need to be able to use that nurses note to recall the days events. If you are charting factual information, it shouldnt matter if you use names.

My sentiments exactly. If something is reported to me I will chart "Called to unit by LPN Smith..." I will subsequently will chart what my assessment showed, but I see this as protecting the other staff as well. They saw the problem and notified the Supervisor. They did their job, now it's my turn to do mine. I will not chart anyones name if the problem is not a physical problem.

djsrn · Dec 29, 2004

Well, some places insist that you do not use names, while others encourage it. So you need to ask the Supervisor for the policy at your place of employment.
I know that if there is something that I need to chart like: reported c/o pain to S. Doe, RN, Charge Nurse, I will do so. Especially if that is what I was told to do by a Supervisor. Report it to her and let her handle it. I have seen my name charted on in this fashion many times. You expect it if you are in charge.

What if someone charts that they told you something about a patient, but they really didn't. The patient dies,the family sues and they see you were told about what was going on, since it was put in the chart, and it looks like you didn't do anything about it? If you can't tell, one of my biggest fears is being sued!!