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Do's
and Don'ts of Nursing Documentation
Nurses
are well aware of the standard, which states that if a certain
matter affecting patient care is required to be charted and it
is not, the overwhelming presumption is that it may not have
been done. Good documentation will help you defend yourself in a
malpractice lawsuit, it can also keep you out of court in the
first place. The following excerpts are courtesy of NSO
Risk Advisor-January, 1977.
Do's
- Check
that you have the correct chart before you begin writing.
- Make sure your documentation reflects the nursing
process and your professional capabilities.
- Write legibly.
- Chart the time you gave a medication, the administration
route, and the patient's response.
- Chart precautions or preventive measures used, such as
bed rails.
- Record each phone call to a physician, including the
exact time, message, and response.
- Chart patient care at the time you provide it.
- If you remember an important point after you've
completed your documentation, chart the information with a
notation that it's a "late entry." Include the
date and time of the late entry.
- Document often enough to tell the whole story.
Dont's
- Don't
chart a symptom, such as "c/o pain," without also
charting what you did about it.
- Don't alter a patient's record - this is a criminal
offense.
- Don't use shorthand or abbreviations that aren't widely
accepted.
- Don't write imprecise descriptions, such as "bed
soaked" or "a large amount."
- Don't chart what someone else said, heard, felt, or
smelled unless the information is critical. In that case,
use quotations and attribute the remarks appropriately.
- Don't chart care ahead of time - something may happen
and you may be unable to actually give the care you've
charted. Charting care that you haven't done is considered
fraud.
For
More Information
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Your
license may depend on proper documentation- Who
among us hasn’t whipped through the last 30 minutes of our
shift in order to ensure a timely departure? We all have
lives after work, piano lessons for the kids, gym dates or
happy hour. What do you sacrifice when you want to get out
on time? I’m guessing it may be your charting....
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Proper
Charting For Nurses And Other Health Care Professionals-
The following are some tips to keep in mind when
charting. These are not all inclusive but they do
provide a general guideline for the nurse and other health
care professionals. [Male Nurse Magazine Article]
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Documentation
is Crucial to the Medico-Legal Process- ONE OF THE
MOST critical aspects of nursing--proper documentation--is a
concept introduced to students in the earliest exposure to
nursing principles and practice and bears great importance
in the medico-legal process. [Forensic Nurse Magazine
Article]
-
8
Common Charting Mistakes To Avoid- Here’s advice
that can help keep your charting at its best--and keep you
out of legal trouble. [NSO Risk Advisor, July 1992]
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Surefire
Documentation: How, What, and When Nurses Need to Document-Explains
how, what, and when to document for nearly 100 on-the-job
situations. Provides specific information on: caring for
patients, dealing with challenging situations, and handling
difficult professional problems. Includes pertinent
information highlighted in boxes
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Nursing
Documentation : Legal Focus Across Practice Settings-It
is the only book of its kind to combine legal issues with
charting methods and an extensive review of practice
settings where documentation varies greatly...
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Charting
by Exception Applications: Making It Work in Clinical
Settings-Practical manual for nursing
administrators or supervisors on implementing charting by
exception (CBE), an time-efficient and cost-effective
method for documenting care delivery.
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Avoiding
Malpractice: 10 Rules, 5 Systems, 20 Cases- A
lawsuit
for malpractice is emotionally devastating for a nurse
practitioner, and
obviously arises out of a tragedy for a patient. I believe
there is a place
for preventive law, just like there is a place for
preventive medicine. I would rather work on preventing
malpractice than litigating it....
-
The
Health Care Provider's Guide to Facing the Malpractice
Deposition-Designed to equip those in the health
care industry with the tools necessary to come out of a
malpractice deposition with as few 'bruises' as possible.
Topics include law and legal thinking, standard of care,
preparing for the deposition, and common forms of
interrogation.
-
Nursing
Malpractice : Liability and Risk Management-Students
and professional nurses at any level of clinical practice
will find this book to be a vital resource on the basic
legal concepts and principles of malpractice, liability,
and risk management, and their implications for the
profession. The book also provides detailed strategies for
dealing with these issues.
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NURSING LEGAL ISSUES
