Why can't you write people's names in your note: Rationale?

merlee · Dec 31, 2011

Your notes are appropriate. It is okay to document who you spoke to, the names of docs you have contacted, and other info. I was not taught to 'never' use names but to be careful in documenting how and what!

Unless you saw Nurse Jane place the probe on too tightly, all you know is that you removed the probe and the area underneath it is excoriated. What if someone, like a parent or doc, had placed the probe on? You can only document what you know, what you see, what you did, etc. No speculation, no opinions, no guesswork.

Best wishes!!

Sehille4774 · Dec 31, 2011

Thanks...that sounds alot closer to how I was instructed with charting!

Just the facts, nothing more, nothing less.

I also tend to agree..that if I didn't witness something happen (in general)...How the heck can I know who did what?..ect...I am very reluctant to point that blame finger.

Happy New Year!

Grace Oz · Dec 31, 2011

hey all!
ok documentation experts :) this one is for you!
this might be a duh kind of question...but i am really interested in finding the reasoning. i am looking to adapt my current practices for the safety of my own license if necessary.
i was working with a nurse last night who said that nurses are never to write other names of nurses or managers in our notes (as a general rule, not institutions policy) and most nursing schools teach this.
ok. fair enough. but she could not tell me why. (of course i know you never assign blame in your note to another nurse...ie: kim left the pulse ox probe on too long which caused excoriation of the l thumb) lol.
let me give you some examples of how and why i have been occasionally writing names...
also keep in mind, i work in home care, night shift..we have to write detailed narratives and their are not many people around besides the parents and 5min in the morning with the oncoming nurse to verify or witness that i am doing my job at all
" 1000: clinical manager jane doe here to review equipment and for monthly patient eval."
i would think that one is a good thing because it documents that the office is following up with the patient.
or
"2200: equipment company notified regarding faulty pulse ox machine, voicemail left with clinical manager jane doe, back up machine working without issue, will monitor"
the point of this is to document that i followed up and notified the proper people, per policy, for my safety and the patients safety.
or
"0700 pt stable at end of shift, no change in condition. report given to j. doe, rn, patient left in her care at end of shift.
this one just documents who i left the client with at the end of shift..if i just say "homecare nurse" and dont specify who i saw...in theory anyone could have taken over right?

two rules by which to practise:

~ 1) "if it isn't written- it didn't happen". always document document document.

~ 2) always remember; whatever you document/chart/write, might one day have to stand up in a court of law.

i see nothing inappropriate with you charting/documenting as you have exampled here above.

allnurses Guide · Dec 31, 2011

To be honest I can't remember ever hearing it said "never use a nurse's name in your notes".

I work in home care too, and I feel it's actually more important to write the notes as you described them because working in a decentralized fashion as we do poses all sorts of possibilities for wires to get crossed (I have the scars to show for it :)).

If I place a call to a doctor and leave before a callback or I will be off I write who I spoke to and when. It would be especially important for things like the RT visit to check vent equipment or any kind of DME safety check. If the RN supervisor, manager or whoever visit during my shift I chart that they were there. I do not elaborate for they have their own methods of documenting a visit. When I leave I write "report given to" or "left in care of"

They probably don't want you to write stuff like "Mary left a big huge mess for me to clean up" and the like. :-)

carolmaccas66, BSN, RN · Dec 31, 2011

Sorry, no-one I know has been told you can't use other people's names in documentation. Is this what they are teaching now, or only in other schools? You can use any name you want, as long as you put their title, date, time, what it is regarding, etc.

I have never been told by anyone you can't use someone's name. It's not inappropriate.

It never ceases to amaze me how people get incorrect information given to them all the time on this site! I wonder who was telling you this, and where this is being taught. You can document anything in medical notes, even if a patient swears or curses - I have done many medical documentation transcriptions for court etc, & you must always type exactly the swear/curse words a patient uses.

You can document anything at all ina professional and non-emotional manner. Present facts only - and only what you saw with your own eyes; not what someone else said they saw or what you think you saw.

carolmaccas66, BSN, RN · Dec 31, 2011

Sorry, no-one I know has been told you can't use other people's names in documentation. Is this what they are teaching now, or only in other schools? You can use any name you want, as long as you put their title, date, time, what it is regarding, etc.
I have never been told by anyone you can't use someone's name. It's not inappropriate.
It never ceases to amaze me how people get incorrect information given to them all the time on this site! I wonder who was telling you this, and where this is being taught. You can document anything in medical notes, even if a patient swears or curses - I have done many medical documentation transcriptions for court etc, & you must always type exactly the swear/curse words a patient uses.
You can document anything at all in a professional and non-emotional manner. Present facts only - and only what you saw with your own eyes; not what someone else said they saw or what you think you saw.

BluegrassRN · Dec 31, 2011

I work in a hospital. Our risk management department is very clear in their instructions. They absolutely request that you use a coworker's name if you are referring to them in a note.

For example, they say never to use "Physician notified." but rather always to say "Dr. Smith notified." Instead of "Discussed pt status with charge nurse" they instruct us to state "Discussed pt status with R. Jones, charge nurse."

I always use names in my clinical notes, when applicable. Notes should be clear. There should be no ambiguity as to which physician, nurse, respiratory therapist, etc is being referred to in a note.

carolmaccas66, BSN, RN · Dec 31, 2011

Apologies for my previous post. For some reason, the words jumped around and 'BR' came out in the post after I've hit RETURN on the keyboard.

I DO NOT LIKE this format, it is hard to see and very difficult to use.

caliotter3 · Dec 31, 2011

Every one of your examples is an example that I use in my home care job, so of course, in these instances, I agree with you. I believe you have a good handle on the concept. An example of what not to chart might be: "Lucy Smith LVN did not administer routine ordered iron tablet at 2200 last night". Accusatory entries not acceptable, even if true. If you want to finger Lucy, you could write a communication note about the incident and give it to the supervisor, but a more professional way to do it is to write the comm note detailing how you noted the tablet was not given, but leaving out Lucy's name. The supervisor will figure out it was Lucy.

nurseprnRN, BSN, RN · Dec 31, 2011

whenever people tell me something like this i ask them to show it to me in writing. if "everybody"knows thisandsuch, then it should be in a good nursing textbook on the shelf over there, right? or in the facility policy on documentation? they never can.

talaxandra · Dec 31, 2011

I work in a hospital. Our risk management department is very clear in their instructions. They absolutely request that you use a coworker's name if you are referring to them in a note.
For example, they say never to use "Physician notified." but rather always to say "Dr. Smith notified." Instead of "Discussed pt status with charge nurse" they instruct us to state "Discussed pt status with R. Jones, charge nurse."
I always use names in my clinical notes, when applicable. Notes should be clear. There should be no ambiguity as to which physician, nurse, respiratory therapist, etc is being referred to in a note.

I always use names, too - there's no way I'll remember which doctor, AH person, family member I spoke to months or years after the event. An extract from my notes last night:

"Tachycardic (125bpm), febrile (38.4), hypoxic (90% on RA, 98% on O2 4L/min) and tachypnoeic (26) - covering RMO X. Whoever (bp 1234) notified - no intervention, monitor. An hour later John had worsening dyspnoes (unable to speak in full sentences, requiring several breaths between mouthfuls of water) - vital signs otherwise unchanged - covering RMO Whoever notified - reviewing John at time of report."

(Clearly John and Dr Whoever are pseudonyms and details have been changed on the remote chance that someone could work out who I'm talking about based on this slender information!)