Documentation Issues

I received a phone call from a nurse that had been told that it was against the law to use other staff members' names in nursing notes. This is not true. It is preferable to use other staff members' names in addition to their title so that it is clear which staff member was involved. For example: instead of "I reported the low BP to the charge nurse" document "I reported the low BP to charge nurse Ned Nurse."

Remember that staffing records and other administrative records can disappear and the documentation may be the only record of which supervisor, co-worker, doctor the nurse spoke with. Good documentation is a Good Defense. For more information about the law and documentation see Who Cares About Documentation?