Avoid noting that you have informed a manager or physician of an event if you have only mentioned it casually in the elevator or restroom. Do not record other patients' names in the medical record. Use roommate, initials, or a room and bed number to describe the other patient. Avoid gaps in time and jotting between lines. Never obliterate material on the record by erasing or using white-out, felt tip markers, or typewriter's Xs.
Similar rules apply to documenting in an electronic record.
Never make or sign an entry for someone else or have another person make or sign an entry for you. If you are asked to countersign an entry, check its accuracy. Your signature makes you as responsible for the entry as the original recorder. If you are signing on an electronic record, always protect your access code and electronic signature code. And Your Employer Staff nurses need to act as risk managers to protect themselves and their employers.