Charting and Documentation


 
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The medical record is a legal document and is used to protect the patient as well as the professional practice of those in healthcare. Documentation of the care you give is proof of the care you provide. Any attorney or risk manager should be able to reconstruct the care the patient received after reviewing a chart.

Charting should include assessment, intervention, and patient response. Charting should occur when a patient is transferred - before, during, and after - to another unit in the facility, or to and from another facility. It should also occur for discharge planning and discharge instructions. A variety of formats are used to document care including hand-written flow sheets, nurses' notes, and electronic documentation.

Charting is objective, not subjective. This means chart only what you see, hear, feel, measure, and count - not what you infer or assume. All nurses know that if it wasn't charted, it wasn't done. Attorneys consider the patient's complete and accurate medical record the most reliable source of information on the care of that patient. Proper nursing documentation prevents errors and facilitates continuity of care.

Charting should include not only changes in status, but what was done about the changes. For instance, consider a patient whose condition is deteriorating and the nurse charts her observations and discussion with the primary care physician. However, the physician fails to take corrective action and the patient deteriorates further. The nurse takes no further action. Should the case go to court, it may be concluded that though evaluation and documentation of the patient's condition occurred, the nurse had a further duty to the patient to report her observation and the lack of medical intervention to the supervisor, who should then have consulted the chief of medical staff.   

It is also prudent for nurses to read the nurses' notes at the beginning of the shift before assessing the patient or charting. This will help determine changes in the patient's condition, and will enhance any information gleaned from hand-off communication obtained at changed of shift.

Charting should be completed as close to events as possible, but after, not in advance of, the event. Results of a treatment or medication are not always what were intended, and if completed in advance, it will be an error in documentation. For example, the nurse may have to immediately respond to another patient's need for assistance, and the treatment or medication already charted was never completed. Always chart with objective terms so as not to cast doubt on the entry. Stay away from words like, "appears to be," "seems to be," or "resting comfortably."

Always chart only your own observations and assessments. If you must co-sign charts for someone else, always read what has been charted before doing so.  Co-signing or charting for others makes the nurse potentially liable for the care as charted. It is also good practice to chart a patient's refusal of care and/or treatment, as well as the education about the consequences of the refusal. In additions, always clearly chart patient education.

When an error in charting has been made, a single line should be drawn through the error, the correct entry placed above, or next to, the error, and initial or sign, and date the corrections. Finally, never alter a record at someone else's request, identify yourself after each entry, and chart on all lines in sequence to ensure that additional entries cannot be inserted at a later date.

Always follow the facility's policy with regard to charting and documentation.

Resources:

Guido, G. (2001). Legal and ethical issues in nursing. Upper Saddle River, NJ:Prentice-Hall, Inc.

Schiavenato, M. (2004). Quick-E charting: Documentation and medical terminology - Clinical nursing reference. Orlando, FL: Bandido Books.

Copyright 2008- American Society of Registered Nurses (ASRN.ORG)-All Rights Reserved



 
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Articles in this issue:

Masthead

  • Masthead

    Editor-in Chief:
    Kirsten Nicole

    Editorial Staff:
    Kirsten Nicole
    Stan Kenyon
    Robyn Bowman
    Kimberly McNabb
    Lisa Gordon
    Stephanie Robinson

    Contributors:
    Kirsten Nicole
    Stan Kenyon
    Liz Di Bernardo
    Cris Lobato
    Elisa Howard
    Susan Cramer

  • Recently my boss questioned my charting on a patient ...I wrote that the patient was (non-compliant and combative in my note ) she said that this was not allowed in Florida nursing I have been charting using these words for 10 years when they have fit the patient. Can u give me some info insight about this. thank u, RN

  • It is really a nice and helpful piece of info. Im glad that you shared this helpful information with us. Please keep us up to date like this. Thanks for sharing. ceeeacgfefak

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