How to Chart Like a Champ

April 10, 2017, 9:00 AM

I LOVE charting. Every time a new form is thrown my way, I get the butterflies. See, I have WAY too much time on my hands and never have enough to do, so giving me more documentation fills that void in my heart and reminds me why I do what I do.

Said no nurse EVER.

Charting was by far my least favorite part of nursing.

But as a malpractice attorney, I have newfound respect for good documentation. It can make or break a case. About 90% of the evidence in a malpractice case involves the patient’s medical record. The Plaintiff’s (patient’s) attorney will use the record to prove the elements of his case. Poor documentation makes his job easy. Don’t make his job easy.

So what is good nursing documentation? Good documentation serves the overarching purpose of assuring high quality patient care. It also serves the specific purposes of:

  • Acting as a vehicle for communication among healthcare team members;
  • Assisting in decision-making (i.e. diagnosis, treatment, etc.);
  • Documenting standards that must be met for third-party reimbursement;
  • Providing legal protection to you and your employer, including:
    • documenting patient care meets safe, effective, and legal requirements; and
    • documenting compliance with standards of care and standards of accrediting/regulatory agencies.

Keeping those purposes in mind, there are 5 important principles that apply to good nursing documentation. Good nursing documentation is:

  1. Valid

If what you are documenting does not serve one of the specific purposes, it does not belong in the record.

Stick to the facts; your (and even the PATIENT’S) opinions and accusations are irrelevant to delivering quality care. But what you say CAN and WILL be used against you in a court of law.

DON’T engage in chart wars! For example, one nurse wrote in the patient’s medical record, “ I called the patient’s OB/Gyn three times, but as usual, he did not call me back.” You just became the Plaintiff’s STAR witness in his case against the doctor and your employer. You might want to update your resume.

  1. Accurate

Beware of default settings. Always review and edit default data to ensure only patient-specific data is recorded. All irrelevant data should be removed.

Be precise and quantify when possible. It’s also good practice to use a patient’s own words to describe symptoms.

  1. Trustworthy

In order to be trustworthy, your documentation should:

  • Be clear;
  • Describe, not label;
  • State facts, not value judgments;
  • Be concise;
  • Be legible;
  • Carefully utilize acronyms and abbreviations;
  • Not leave blanks; and
  • Be specific, avoiding general terms and vague expressions

Also, don’t use any term unless you are 100% sure of its meaning.

  1. Timely

In a medical malpractice case, date and time are critical in establishing timely responses to a patient needs. It’s important to remember that the electronic health record creates an audit trail with time-stamps of all information created and/or amended and that patients have a right to receive this information and WILL get it.

When possible, resist the temptation to document at the end of a shift. You may forget key information and you won’t remember it when it counts. Most malpractice cases don’t go to court for 2 years or more. Ask yourself how well you remember the care you gave John Williams two years ago? Who’s John Williams, you ask? Exactly.

Also, healthcare team members need contemporaneous information to make good decisions about patient care.

But, better late than never. If you’re documenting a past event, document using the date and time of the entry and then note the date and time the event occurred.

NEVER document in advance.

  1. Complete

You’ve heard it a million times, but always remember: IF IT WASN’T DOCUMENTED, IT WASN’T DONE! You will never convince a jury that you remember doing something two years ago that wasn’t documented.

If information serves one of the specific purposes of documentation, then it should be included in the record.

Incomplete information may lead to:

  • Misdiagnosis;
  • Medication errors;
  • Prescribing the wrong diagnostic test or treatment; or
  • Other patient safety concerns, inefficiencies, or poor quality of care

Common Documentation Errors

Be especially careful not to commit the following common documentation errors:

  • Failing to record pertinent health or drug information;
  • Failing to record nursing actions;
  • Failing to record medications given;
  • Recording in the wrong patient’s chart;
  • Failing to document discontinued medications;
  • Improperly using a medical term;
  • Failing to record drug reactions or changes in patient’s condition;
  • Transcribing orders improperly;
  • Writing illegible or incomplete entries;
  • Recording non-factual information; and
  • Engaging in irrelevant “conversations” with other staff members

Obviously, some are more or less applicable depending on the type of charting you do, but these principles and errors apply to just about every area of nursing documentation. If you’re unsure or curious which areas of practice require the most diligence, see my previous post regarding the Top 10 Mistakes Virginia Nurses Make. It will alert you to the practices that present the greatest risk of legal liability.

Plaintiff’s attorneys review the medical record before deciding whether to take a case. Meticulous charting can prevent many, if not most, lawsuits from being filed, and bad charting is very difficult to cure. As your grandmother always said, an ounce of prevention is worth a pound of cure.

Believe me, I know your time is limited, but I also know you don’t have time to get sued. If you don’t believe me, read next monh’s post, “What will getting sued cost you? Nothing or Everything.”

So, what do you think your employer could do to make charting easier or more effective for you? What, if anything, have they already done to make it easier?