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    ​018 联署医疗记录有什么后果?
    日期:2015-10-06 16:47:57    来源:奥医教育

    在日常执业中,有的护士会要求我们一起在一份医疗记录上署名,以保证这份记录的权威性,有的时候联署者并不完全了解或参与了护理操作的实施。那么,联署者到底该承担什么样的责任?碰到这种情况我们该不该联署?
     
    What Does It Mean to Cosign a Record?
    Carolyn Buppert, MSN, JD
    Question
    If I cosign that another nurse has correctly drawn up a medication, what does that mean, exactly?
     
    A nurse asks: "What is the legal implication of cosigning a medication (insulin, for example) with another registered nurse (RN)? I am signing that I watched the nurse draw up the correct amount of medication. But what he or she does with it after that is his or her responsibility, correct?"

    First, don't cosign a record if you haven't directly witnessed the activity. If you are witnessing an activity, specify what you have witnessed. For example, if signing that you witnessed the nurse draw up the medication, write "I witnessed Ms. Smith draw up the insulin and agree that it was the dosage ordered."

    If a hospital or facility requires cosignatures, the hospital or facility should have a policy on cosignatures. The policy should specify when a cosignature is required and the cosigner's responsibilities.

    Some state Boards of Nursing and nursing associations discourage cosignatures, so before developing a policy, check the Board of Nursing Website, as well as the state nursing association Website.

    For example, here is what the Minnesota Nurses Association says about cosignatures:
    There are times when it is appropriate for nurses to co-sign, such as the situation when narcotics are discarded by a licensed nurse with an RN observing for the record, or for documentation requirements for certain medications and procedures. In this case you are observing the activity, and fulfilling a legal or health related policy for double-checking.[1]
     
    Here is what the Texas Board of Nursing (BON) says, in the context of RNs signing graduate nurses' (GNs') or graduate vocational nurses' (GVNs') notes:
    We highly discourage a nurse from co-signing anything he/she did not directly witness or immediately verify personally. Co-signature implies that the signer agrees in total and was either witness to, or went immediately behind the GN/GVN to assess and verify the findings of the GN/GVN.
    Co-signatures may be necessary for certain nursing tasks, such as witnessing the wastage of a unit-dosed amount of a narcotic. Such requirements are beyond the jurisdiction of the BON. Contacting the appropriate licensing authority, or an applicable credentialing organization (such as the Joint Commission on Accreditation of Hospitals and Organizations) for any regulations specific to the practice setting, is recommended.
     
    With respect to RNs cosigning licensed vocational nurses' (LVNs') documentation, the Texas BON says:
    In general, BON staff does not recommend a nurse co-sign anything unless he/she has directly witnessed an act (such as narcotic wastage) or has gone behind another nurse and personally performed the same assessment with the same findings. As discussed above, each licensed nurse is responsible for accepting assignments that are within the educational preparation, experience, knowledge, and physical and emotional ability of the individual nurse [Rule 217.11(1)(T)]. Both LVNs and RNs are required to document the nursing care they render; each is held accountable for doing it accurately and completely.
    The question of a RN co-signing after a LVN most often arises in situations when an attempt is made to expand the LVN's scope of practice by holding the RN responsible for expanded tasks performed by the LVN. The RN co-signing for something that is beyond the LVN's scope of practice does not legitimize the LVN's actions. A nurse never functions "under the license" of another nurse. Therefore, if a patient requires a comprehensive assessment performed by a RN, the assignment (or a portion thereof) may not be given to a LVN. If such an assignment is inadvertently given to a LVN, he/she is responsible for notifying the nurse who made the assignment that it is beyond his/her scope of practice to perform the assigned task. Each nurse has a duty to maintain client safety [217.11(1)(B)] that includes communication with appropriate personnel. Position Statement 15.14, Duty of a Nurse in Any Setting, further explains a nurse's duty to a client.[2]
     
    原文链接:http://www.medscape.com/viewarticle/811976
     




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