Ask Nurse Jesse: Documentation

Anonymous Nurse: May nurses document something that another nurse has done if both nurses sign?

Nurse Jesse: Nurses should only be documenting what they personally observe or do.

4723-4-06 (Ohio Administrative Code) states: (E) A licensed nurse shall, in a complete, accurate, and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the patient, and the patient’s response to that care.

Documentation should be completed in real time and only by those directly involved in the care of that patient. You should never chart something you did not witness or do.

If you have concerns, I would suggest contacting the Board of Nursing.