An employee who no longer is with our practice has not completed charting, or worse yet, has not signed off on many of the nursing notes. Can a supervisor sign off with a note that the employee no longer is employed in the facility? These omissions were detected in our routine, monthly chart review.
Nancy Brent replies:
The patient care record should not be used for anything other than documenting information about the patients care, health status, treatments and results and so forth. It is not a place to document employee or employment issues.
As you probably know, the supervisor can finish any incomplete documentation by factually, truthfully and accurately adding information necessary to complete the patients chart. The entry should not be back dated but rather reflect the day on which the documentation was done. The supervisor should sign the entry with his or her name, credentials and title.
If the supervisor is documenting information given to him or her by another staff member, rather than documenting something he or she has personal knowledge of, the supervisor simply can write something such as: Mary Jones, RN, informed me that on Tuesday, Oct. 16, the patient told her he felt good. The reader then knows that the supervisors entry reflects another persons information about the patient.