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At my facility when a nurse forgets to sign something with her full name and just uses initials, we are told to fill it in. Is this legal?

Friday February 8, 2013
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Question:

Dear Nancy,

I am a staff RN. At my facility when a nurse forgets to sign something with her full name and just uses initials at the end of her charting or signing off on a physician’s order, we are told to fill it in by putting ‘signed for, then the nurses name, then slash, then our name.’ Is this legal?

Carolyn



Nancy Brent replies:

Dear Carolyn,

Any time one signs another's name on a legal document, with his or her consent, including any form in the medical record, and then adds his or her name after a slash, it signifies that you, as the individual signing the document, have personal knowledge of the information in the entry and it is accurate. It seems that in the situation you described, those conditions were not met.

Doing so without personal knowledge and with accuracy now shifts the burden to you in terms of the information placed in the entry. It can raise problems for you as to why you signed the entry without meeting the required terms, or if the issue involves a medication order or other order from a physician or other healthcare provider that proved to injure the patient in some way.

The best principle to follow whenever possible is an old one — the one who documents is the one who signs the documentation.

If your facility policy requires the nurse to sign with his or her full name, then that policy should be followed and when it is not, the person violating the policy should be counseled or disciplined pursuant to the employer's disciplinary policy. Other staff members should not be involved in fixing documentation that does not follow the adopted policy.

A good resource for you to consult about this issue is Debra Sullivan's “Guide To Clinical Documentation,” 2011, Second Edition, F.A. Davis Company. There are other good texts and journal articles on good documentation principles available to you also.

Sincerely,
Nancy




Nancy J. Brent, RN, MS, JD, is an attorney in private practice in Wilmette, Ill. This information is for educational purposes only and is not intended as legal or any other advice. The reader is encouraged to seek the advice of an attorney or other professional when an opinion is needed.

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