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Is it legal for a nurse to sign off on a physicianís order if the previous nurse forgot?

Friday April 20, 2012
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Question:

Dear Nancy,

Is it legal for a nurse to sign off on a physicianís order or documentation if the previous nurse forgot? My employer said we could note the order was signed for by the previous nurse, including her name, a slash and then mine.

Shasha



Nancy Brent replies:

Dear Shasha,

The example you have included in your question when you are signing something in a patient record for someone else is correct, the person's name is documented with a slash and then your name. This shows the reader who actually signed the notation.

However, in the instance in your question, it is not clear if the other nurse did indeed take the order off of the physician's order sheet or other documentation. When you sign for another, you are attesting to the fact the other nurse did indeed do what was required, you have the authority or permission to sign in this manner and you have knowledge that what is at issue was in fact done.

It would seem more prudent for the nurse who forgot to take off the order, to sign his or her own name to the order with the date the sign off takes place. Or, the nurse could document that the order for a certain date, was done on that date and then sign his or her name with the current date.

Discuss this issue with your employer and the risk manager. There is a wealth of information in nursing texts and on the Internet for guidance when signing an entry for another. Doing what is honest and best for you and your facility is the main goal.

Cordially,
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.