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September 2011, Volume 41 Number 9 , p 18 - 19



I'm a staff RN on a medical--surgical unit. The protocol on this unit is for staff nurses to -notify the charge nurse of any change in a patient's condition, and the charge nurse then calls the hospitalist if necessary. The charge nurse on my shift gets upset when a staff nurse documents her name, rather than just her position (for example, "charge nurse notified...") in the medical record and communication book. She says that using her name sounds like the staff nurse is placing blame on the person being notified.In nursing school, I was taught to document specific names, not job titles. Has this standard changed?-K.B., TEX.Not at all, says our legal consultant, who congratulates you for remembering the importance of documenting specifically the person to whom you communicate important information. If a legal action ensues months or years from now, much time and expense could be wasted by attorneys researching who was charge nurse on that particular shift. This shouldn't be necessary

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