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

[Sehille4774]

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?

[One Flew Over]

The only time I was told that it is inappropriate to use a name is when you are referring to another resident/patient (as in a patient-to-patient altercation) and I believe in that instance it's acceptable to use 'roommate' or room number if I'm not mistaken.

[NicuGal, MSN, RN]

Oh yes, you should be documenting names. "IV started in right hand by Lucy Two shoes, RN on the first attempt". "Dr. Thomas notified of blood from ETT tube at 1000". Names are very, very important if a chart is ever used in a court of law. You better bet your pants that they will ask you, who did this, who did you notify, what time did you notify, etc.

[xtxrn, ASN, RN]

If I talked to a specific supervisor, doc, or other nurse, by God their name went in the chart w/date and time. Period. If they are pertinent to the situation, they get named in the role they played. :)

[Sehille4774]

Awesome..thanks for all the responses!

It was just such an off the wall comment..our debate got a bit heated. See, that's why its never good to believe everything your hear, lol. Maybe she was trying to punk me XD.

Good review of general charting principles at any rate.

I kinda had the feeling too that since I am working out in the field, I should at the least always write who specifically I give the care of the child over to when I go home and ect since we have no way punch in system or records like that the way a facility would.

[GM2RN]

In addition to what everyone else has stated, I will also document what was reported to me by another nurse, doc, EDT, etc. For instance: Jane Doe, EDT, reported to me that she witnessed family giving pt fluids. Pt and family had been instructed by me that pt is to be NPO because...

This actually happened and I needed to be able to document that I had been made aware of the situation and what had been done to rectify it, etc. Whenever I document something told to me I make it clear that it was witnessed or done by someone else and was only reported to me as the nurse in charge of the pt.

[KaroSnowQueen, RN]

Now I have to say my last job we were told not to write any other nurse's name in the notes, only to refer to them vaguely as in "Reported such and so episode of pt (change in cond, pt c/o, whatever), as it would implicate those individuals in case of a lawsuit. OK to write called Dr Wonderful, tough.

[talaxandra]

Maybe it's because Australia is generally less litigious than the US but I'm far more concerned about ending up in front of the Coroner with inadequate notes than I am about ending up in court because another nurse documented that I'd told her soemthing. If I assist a colleague (by, for example, inserting an IDC in her/his patient) I'll document that I did that myself.

[nursel56]

I guess it must vary to some extent based on the environment you are in, but when we are out in a home and it's just us- we must make phone calls in order to have someone else assess (or confirm) a significant change in the patient/client's condition.

Sometimes it's so bad we just call 911. Other times I will place a call to the Case Manager. If I get voicemail, or I get "I'll call you right back" and they don't call back, I'd be a little more worried that it would appear that I did not follow proper procedures than I would about making that person look bad if it ever came to a lawsuit. I've been "hung out to dry" on more than one occasion re: timely callbacks.

Ideally, each nurse writes an accurate account of phone calls made, to who etc in the communication notes, but this doesn't always happen and the only way you can make sense of what was going on is to use the other nurse's name. We often aren't able to give face to face report to another nurse. We're supposed to use the office to contact other nurses if we have questions . . I'll be charitable and just say it's not very efficient or timely. :).

I've never been involved in a lawsuit in my years in nursing but it's still good practice to chart things "as if" - you never know.

[hiddencatRN, BSN, RN]

I was taught in nursing school that it was important TO use names. No "MD aware" but "MD Doe aware, discussed xyz changes in plan of care". At work we chart the name of the nurse we hand off the patient to when we leave, and for certain things like EKGs and critical lab values we're prompted to chart the name of the doctor that reviewed the EKG and the critical value.

[talaxandra]

I got a call from the lab the other night about an Hb of 79, which clearly is a mandatory notification because my patient's last three Hb's were 80, 80 and 82 and she's got multiorgan failure, two ICU transfers for sepsis this admission, a fungal infection on top of PJP...

So - not worried that she's bleeding from anywhere, but if path are going to take my full name for thir documentation I'm going to document "Notified by pathology that Hb was 79 - covering RMO J. Doe (bp 1234) notified - aware of clinical context and ongoing anemia -> no intervention at this stage, 1 unit PC prescribed during AM dialysis, repeat FBE post."

[thekidisback]

I use names on my notes. But only for certain simple things like "received report from Lisa, RN" or "Dr. Smith made aware"

[psu_213, BSN, RN]

I always use proper names. "EKG completed and shown to Dr. Smith." "Report to Mary, RN." "Informed Dr. Jones of critical lab result (K=6.2)." Two things here: first, I generally trust the doctors and nurses I work with. However, everyone becomes busy. Dr. Jones may honestly have forgotten about the lab result. Now, if he does not act on it, I will bother him again about it. However, if something were to happen to the pt in the meantime, it's not going to help me if I just have "MD informed" charted. I am certainly not charting it this way to call the doctor out or shift all the responsibilty to him/her...however, if something does happen I don't want it to look like I was sitting on this information. Second, re: using the nurse's name: in the ER we had a situation where a nurse has said that another nurse left without giving report on a pt destined for the ICU. There was some type of antimosity between these nurses before the incident. The nurse that left swore up and down (days after the 'incident') that she did give report before leaving for the night. I would hope no nurse would throw me under the bus (boy, I hate the phrase!! can't believe I just used it...ugh) like that, but I don't want to take my chances.

The other time I will chart someone's name is if they did a procedure. For example, "IV established by John, RN: 20ga, left forearm." That way, if it gets infected, it is artieral not venous (it has happened, see the Supreme Court case Re: phenergan), etc. it does not come back on me (at least in full ). I know this is CYA and is not in the true spirit of collegiality, but, then again, I don't want a necrotic arm on my license, so to speak.