During nursing school, I didn’t comprehend the significance of nursing documentation. During my 3rd semester, the faculty chose to give us a short lesson on nursing documentation. The instruction lasted two hours, and I was glad because I had more important things to worry about, like passing tests!
Most schools still don’t adequately prepare their graduates to chart with a legal dilemma in mind. Now as a staff RN in a busy ICU, it’s easy to see the importance of having clear and concise documentation.
There are many reasons to be competent within your documentation. What you chart has considerable bearing on future assessments by the interdisciplinary health care team and your patient’s plan of care. Accurate charting can also assist in the development of research to improve future charting practices. Finally, what you chart can have a major impact on your life and whether you keep your license.
Everything you type or “check box” in the electronic medical record stays in that patient’s chart for years to come. If a legal situation ever arises, anything that you have written may be presented as evidence before a judge and jury. Depending how much time has passed, you may not even remember the situation very well and will have to rely on what you wrote to defend your actions.
Regardless of where you work, a deteriorating patient condition requires you to elicit help and obtain a response from the physician or advanced practice nurse.
If you document anywhere in the chart that your patient’s condition or overall status has declined in any way (nausea, pain, fluctuation in blood pressure, fever), make sure you chart the details surrounding your assessment along with your intervention and follow up evaluations. If you only chart that the patient has a problem, but no other notes regarding what you did for your patient, a court of law will likely find you negligent. Make sure you note the times and dialogue of your physician notifications and the telephone orders they gave you (or if they didn’t).
The mantra of legal nurse consultants is: “if it wasn’t documented, it wasn’t done”.
I try to stay away from abbreviations. Typing out the whole words takes very little time and ensures definite clarity. Abbreviations saved time when documentation via pen and paper was commonplace, now not so much. There are so many revisions of institutional and JCAHO “Do Not Abbreviate” lists, today, that it has become hard to pinpoint the most current version. I simplify my practice by refraining from using most abbreviations. If there is any chance of a jury misunderstanding a term, use specific descriptors and non-abbreviated words in your charting.
Redundant charting can set you up for an inadvertent discrepancy and furthermore, it is a waste of your time. If I write in a nurse’s note that my patient has received a PRN medication, I direct anyone reviewing the chart to simply “see eMAR”. If there is a change in a body system assessment: “See ICU Assessment”. If any part of your testimony in court (including your documentation) is proven to be incorrect or negligible, the entire record you have created and account for becomes questioned. Any error in your charting can become the weakest link, causing major consequences for you and the defense.
Just the Facts…
This is probably the most commonly made mistake in documentation. Until recently, I would often type “patient resting comfortably in bed.” How do I know if that patient is resting comfortably? What if (s)he is intubated and sedated? Is there any reasonable way for me to really be sure that my patient is resting comfortably? If you think your patient is sleeping peacefully, are you going to tell a future jury with 100% certainty that (s)he was sleeping and not playing possum, sedated, or in a coma?
I also used to type “patient tolerated _______ well”. Did you ask the patient? Did they tell you how they tolerated the walk?
Instead of these general assumption phrases that are based only on subjective data, describe the objective data you notice that enables others to draw their own subjective conclusions. “Patient lying in bed, snoring, eyes closed, respirations regular with rate of 16, skin warm and dry.” That sentence tells anyone reviewing the chart that the patient was probably sleeping or at least resting in no apparent distress. Your patient tolerated a walk well by “denying shortness of breath, verbalizing no discomfort, and ambulating without assistance around nurse’s station and back to room”.
Don’t use labels such as ‘violent’, ‘inebriated’, or ‘delirious’; instead, describe what the individual is doing that would paint a picture of that state of being.
If the patient is angry, chart the specific body language cues that tip you off: voice intensity increasing to shout/yell, face turning red, arms shaking, fists clenched, cursing loudly, and posturing aggressive stance in front of nurse.
If the patient is drunk, document the clinical symptoms being exhibited (slurred voice, stumbling gait, smell of alcohol on breath).
If the patient is confused, note what the patient said (in quotation marks) that would lead a jury to believe the patient was indeed confused.
Your reporting should reflect objective clinical nursing judgment and data; chart what is, not what “appears” or “seems”.
A good way to chart only facts is to only record information that you observe and collect through your senses. If you directly see, hear, smell, or touch the occurrence and chart without creating an assumption, it’s probably going to be seen as objective.
When you hear pertinent dialogue by a patient, their family, or a doctor, chart their statement verbatim in quotations, identifying the individual by name.
RN.com (2012) published a list of words to avoid using in your nursing notes:
These descriptors paint you in a negative light and raise doubt towards your competency.
In today’s era, being sued for frivolous reasons has become somewhat of a norm. The longer you practice nursing, the more likely you (and your documentation) are to become part of a legal action. The best way to prepare is to enhance your documentation now while correcting any bad charting habits you currently practice.
Also keep in mind that it is always prudent to confirm that the way you are charting is in accordance to the policies of your institution.
Keep your license safe from lawsuits – paint a clear and objective picture now for that future jury!
RN.com (2012). Professional Documentation: Safe, Effective, and Legal. AMN Healthcare Education Services.