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I was taught it’s a legal document and if you know the name of the person you spoke with that is better and more accurate in case you were called to court to testify as it paints a clearer picture. I was told you want to be clear and concise but thorough at the same time so I put names in there.
That seems sketch. WHY would you be asked to not be specific when charting. Exactly what OT1 said.. it's a legal document, everything they said.
I had the same question years ago. Today, I understand why hospitals prefer that we nurses are not specific and have found a way to mitigate that to stay employed. In case a legal matter arises and depending on what side one is one, a lack of details can be easier to defend. While there are things that do not belong on a patient's record, names in my opinion, do belong there. In an effort to maintain a collaborative approach, we nurses need to keep our own notes as we move along. It works!
When I was a new nurse I was told to never keep personal notes. If it pertained to nursing care, pt care, it needs to be in the chart, nowhere else. The reasoning provided was that if your documentation were ever involved in a court proceeding, EVERYTHING pertaining to that care is discoverable, including your private notes.
Charting accurately with the name of the providers is not defensive charting. It's charting accurately. You chart facts and what happened at the time care was given. No opinions, just facts.
I would document as if the judge is reading your charting. Knock on wood but you’d definitely want to remember what was said by who.
I has been my practice in the twenty-five years of inpatient nursing for major Chicagoland healthcare systems that we never "name" anyone when charting and use the title of the provider or staff person as mentioned in your discussion. If you are concerned about being called to testify in a future court case, the care team providing care to a particular individual on a particular shift/date can be obtained through other means...its just professional etiquette (among other ethical reasons) document as suggested and only to document facts - no opinion.
The patients can now see the call notes in their chart so I don’t think our names should actually be in there because they could actually contact us or find out where we live and I don’t think that’s appropriate. I think our security is important.
Rising Star
In epic at least your name prints as part of the care team when discharged. If they do a medical records request your full name is all over the chart even if someone never documented it because every entry you make is signed by you with your full name.
Chief
I agree with you—specific names provide clarity and accountability, especially when multiple providers are involved. Generic terms could lead to confusion later on. It’s better to keep detailed records!
That sounds like a really bad policy, and one destined to cause problems down the road. You're essentially being told to fudge records. In most cases they'll just get filed and it's no big deal, but in some cases accurate information would really matter. And you're being told to make sure things are purposely inaccurate.
No you are not being expected to "fudge records" you are documenting titles of the interdisciplinary team of individuals involved. This is standard professional practice and has been for decades in upscale healthcare systems.
You should absolutely name who you spoke to. What if you ever found yourself in court (god forbid). If they asked who you spoke to you may not remember and back to the old saying, "if it's not charted it wasn't done." As a juror I would question the credibility of the RN not naming names of who they spoke to.
Write the names!!!! It is a legal document and a lawyer will have no trouble finding them out!
Using specific names provide clarity and is less likely to be confused with another doctor or provider if they share names or initials. My previous employer used initials for their documentation for progress notes and it was confusing when two employees had the same initials.I had to include my middle initial to avoid further confusion.
It’s all about accountability. And the law. Of course lawyers play games with that and make no one accountable for the right price. For profit health care employ a lot of lawyers….
I would want to know what their reasoning was and who authorized it. Not naming the person you interacted with could very well explode back in their face. But of course it would all be reflected back on you because ultimately it's your name on that piece of documentation
I was taught to document like I had to testify in court tomorrow. That's exactly what I do.
It’s a legal document. Chart accurately & with detail including names. None of those people will be sitting next to you in a deposition, they won’t be trying to vouch for you. In fact, they will immediately throw you under the bus. You are only accountable to the board of nursing and to the law, not to your supervisors, they do not write laws. Chart for the you that could be testifying in court in five years. That is the best advice a veteran nurse gave me years ago and that is still how I document to this day.
Is the charting or messages documented under a Dr/Provider's name? If so, it is covered, however, I do agree completely, multiple providers filling in as provider is ooo or other issues. It is a matter of CYA, otherwise provider can say it did not happen and it falls on you.
Charting is supposed to be specific, it is their medical record. "If it isn't documented, it didn't happen."
It's to cover themselves... while leaving you out to dry. If in court, YOU will be asked whom you spoke with. How will you know? Will it look as though you are lying? Rules, policies and procedures are for the benefit of the employer NOT the employee!