using names when charting

If we do a task for someone else, we have to chart ourselves. Our legal is of the mind that anyone could write any other person's name in the chart. The only exception is in the case of an emergency.

You must put the last name to make it legal in the courts. I do put names on things that I think are important. Ex. I would put I.V. started by J. Doe RN.

You must put the last name to make it legal in the courts. I do put names on things that I think are important. Ex. I would put I.V. started by J. Doe RN.

The chart is a legal document. Documentation is objective...who, what, when, where, who, and outcome. Nothing subjective. Names and credentials are included.

The chart is a legal document. Documentation is objective...who, what, when, where, who, and outcome. Nothing subjective. Names and credentials are included.

One of you responded you chart the person's name cuz if there are 5 nursing assistants on duty how would they differentiate who they were talking about in court" I just don't see putting a person's name down and making it easier to get someone in trouble. Just like when you have a med error. you don't put it in the patient's chart, you make out an incident report.Does this make sense to anyone?

As for the original question, do they really neglect to teach charting in nursing school?

Jason

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.

I do ask the person that performed a procedure (like a foley, IV, NG tube insertion) to chart what they did to my patient themselves-some do and some don't: I, however, will chart on another nurses' patient if I do something for them. If another RN, LPN or NA witnesses a patient fall, and I didn't witness it myself because I was talking with a doc or in another patient's room, I also include their name in the chart and the incident report-but I never chart that an incident report was filed in the nursing notes-that is a no-no.

It is amazing to me how much variation there is in charting practices....

To the person that asked if nursing assistants can place foleys; they can where I work with the proper training.

To Jason, this is a chat room, I am posting things to discuss, that's what chat rooms are for. do they really teach doctors to be rude in med school?

Thanks to everyone else that gave thoughtful, insightful replies. After reading the "whys" to charting people's names, it makes more sense to me.

As an extern, I ALWAYS put the dr.'s name if we had to page her/him in an emergency or ugent situation.... "0300 page to dr. jones. pt complained of substernal chest pain 10/10 stabbing, O2 applied, no change in pain level."

oops forgot to add, if someone places an IV or some sort of interviention on someone else's pt, then they chart it, not the primary nurse. But yes, in our school we are always taught to use names as it is a legal document and never to use subjectives. I personally use tons of quotes, pt stated, "I can't breathe" and clutched chest. I know some will disagree with this, but if you really feel funny about using names in the progress notes (or where ever everyone reads/charts) chart these interventions in the flow sheet...everyone has access to it, but most don't read it b/c it's usually for nursing notes. I'm not saying this is best but it's perfectly legal to chart here (b/c it's in the chart).

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.