When charting an electronic medical record, where your name is clearly visible as the charter, do you chart as I, RN, writer or what? I was told to chart as RN, but if it became a court case, wouldn’t that be subject to interpretation? Which RN? Isn’t it more clear to write “I called Dr. B regarding pts x-ray results” than to chart “RN called Dr. B”?
Dear Nancy replies:
When documenting patient care in any patient record, the overall objective is to make sure the reader knows the who, what, where, why and how” of patient care. The “who” part not only includes who the patient was but who provided the care and who documented it.
Your example of stating, “RN called Dr. B,” is unclear as you point out, despite your name being clearly visible as the charter. It would eliminate a lot of unnecessary confusion to document “I called Dr. B” or “This charter called Dr. B. Not only does this clarify exactly who did what, it also protects you in the event someone questions whether you indeed fulfilled your legal duties of care to the patient and therefore met both the standard of care and the standard of practice in that situation.