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?
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.
It is CYA but you shouldn't have to feel that it's a bad thing. It should have nothing whatsoever to do with collegiality; you are charting the facts. You could also look at it this way--by NOT charting that John, RN, started the PIV, it will appear that YOU started it and would technically be fraudulent charting.
It is CYA but you shouldn't have to feel that it's a bad thing. It should have nothing whatsoever to do with collegiality; you are charting the facts. You could also look at it this way--by NOT charting that John, RN, started the PIV, it will appear that YOU started it and would technically be fraudulent charting.
I document for two reasons - to communicate what happened while I was caring for my patient, and to cover myself if something goes wrong. I don't ever write something I wouldn't be happy to either read out in court or have the patient/family read - that's not to say I won't document that a patient was, for example, abusive, but I make sure what I write is unemotional and objective.
So if Dr Jones was paged three times about my patient's falling BP before I escalated to registrar review or initiated a MET call, I'm going to write that rather than have it look like I either did nothing while patient was slowly crashing, or have it look like I tried paging someone who was no longer on duty.
And if RN Brown's patient develops urosepsis a week after I inserted an IDC, I'm going to have documented why I inserted a catheter, the doctor who directed it be inserted, the rationale, that I used aseptic technique, and when the unit should consider a trial of void. Being accountable for my actions is part of my role; I don't have a lower standards for that when it comes to my colleagues.
So I was a nurse manager at a SNF and we absolutely told our nurses never to use other workers names. Doctors names were okay(we still preferred generic MD or NP, etc) since we get orders and care advice from them, family member names were okay as well if it was pertinent to our assessment- but not any coworkers. Also not to use "I" but "Writer". And it was because of liability. Calling out someone specifically in your charting is not medically necessary- yes document what happened "pt sustained skin tear r/t gaitbelt use during transfer with aid" etc but do not name the care aid. The specific aid is not part of the medical dictation. If a harm is done like- skin tear, fall, etc... that investigation goes on outside of the EMR and absolutely includes names, times, statements and is provided to the state or authoritative body when requested- but all of that does not go into the patients medical record. The not using "I" I think is just part of professional writing- essays and papers we are taught to never use "I" and to remove yourself personally from the assessment.
So I was a nurse manager at a SNF and we absolutely told our nurses never to use other workers names. Doctors names were okay(we still preferred generic MD or NP, etc) since we get orders and care advice from them, family member names were okay as well if it was pertinent to our assessment- but not any coworkers. Also not to use "I" but "Writer". And it was because of liability. Calling out someone specifically in your charting is not medically necessary- yes document what happened "pt sustained skin tear r/t gaitbelt use during transfer with aid" etc but do not name the care aid. The specific aid is not part of the medical dictation. If a harm is done like- skin tear, fall, etc... that investigation goes on outside of the EMR and absolutely includes names, times, statements and is provided to the state or authoritative body when requested- but all of that does not go into the patients medical record. The not using "I" I think is just part of professional writing- essays and papers we are taught to never use "I" and to remove yourself personally from the assessment.
hope this helps!
You seem to be already aware that all of those names will come out in the investigation anyway, so then why do you hold on to the notion that including their name in the notes increases liability?
You seem to be already aware that all of those names will come out in the investigation anyway, so then why do you hold on to the notion that including their name in the notes increases liability?
This is a holdover from nursing school, years ago, when we were taught to always write in the third person; based on the old APA style guide. As APA has moved to preferring personal pronouns, perhaps nursing education and practice will follow.
But the investigation is private it's not shared with coworkers or family members or other facilities- just between managers and authoritative bodies. People's names in a medical file are not professional- we send copies of those notes with patients to the hospital, to home health, to people's family if requested, to other facilities with transfer, they stay in their medical file for a very long time. AND all other coworkers can read it. By keeping worker names out of medical charting we don't create the conflict between staff, it sounds more professional, and we don't call ourselves out in charting without the investigation to back it up- creating potential reasons for authoratative boards to go digging deeper. It's just not a part of the medical profile.
GM2RN
1,850 Posts
It is CYA but you shouldn't have to feel that it's a bad thing. It should have nothing whatsoever to do with collegiality; you are charting the facts. You could also look at it this way--by NOT charting that John, RN, started the PIV, it will appear that YOU started it and would technically be fraudulent charting.