I work part time in an adult day care center where the full-time nurse often will print out emails that she has exchanged with families and put them in the progress note section. Can this replace writing a nursing note on the topic?
Concerned About Charting Practices
Dear Donna replies:
Dear Concerned About Charting Practices,
It’s challenging for me to address your question without knowing all the facts, including what state you practice in. For example, I am wondering if your employer has a policy that all email communication with a client’s family must be printed and saved in the record. Perhaps when there is a problem, the nurse in question wants to keep a record of the conversation to support a documented note. Certainly printing out emails would never substitute for a written progress note. Refer to your employer’s charting guidelines.
I did consult with Tracey Wolfman, RN, owner of We Care Adult Care, Inc., in New Jersey. She confirms that printed email communication does not replace the written progress notes required by most, if not all, states in adult day service facilities. She suggests you speak to your supervisor if you have any questions or concerns about charting policies in your state and/or facility. Wolfman also advises that you could check with whichever entity licenses adult day services in your state (e.g. state department of health) because they have specific regulations about charting.
Your state should have an association of adult day service facilities that would be able to advise you of state-specific regulations regarding charting and client record keeping.