using names when charting

[djsrn]

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!

[Fun2, BSN, RN]

I agree with Thunderwolf's who, what, when, where, why, and outcome.

Full name, or First initial, and last name, then Title for anyone that administers any type of care to your pt, or any important comments by anyone regarding your pt. You never know when/if you will need this information in the future.

Granted I have only charted on Dr.'s office pt. charts, along with everyone else in the office, so I also always initial under my last statement.

I guess I will learn what's appropriate for hospitals when the time comes! :) However, I think it's better to put too much information, than not enough, but keep it short and sweet at the same time. I sure wouldn't want to have to remember details of something by reading vague charting!

[lovis]

You have a responsibility to write down what the patient has told you, not what your collegues says the patient said...*confusing*. I mean; to be sure you can stand for what you've been told, go to the patient, talk and write. That should keep you on your safe side..and if the patient does agree, you could tell the family. You have to read what's in the charting not what your collegues says that patient said. Second hand info is never the best. thats my recommendation.

/L.

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!!

[Penny Lane]

Thanks to all for your advice even though it wasn't my question. I really enjoy reading this info and I am glad I joined. I'll be entering nursing 4 in two weeks and myself along with some other students will be asking for some classroom time to really get into correct documentation which I feel we did not receive enough education on that subject. Thanks again! :)