It's been many years since I attended nursing school, but I can tell you with certainty that we were not given much instruction on charting if any at all. Instead, the instructors focused on more important things like how to make a hospital fold in the bed sheets and how to bully us during discussions after we had taken a test. There are some things about charting that nurses must know to protect themselves from lawsuits.
I sincerely hope that times have changed, and nursing students are getting more education on the importance of charting correctly. If you can't chart properly, you are at serious risk of being sued for malpractice. All nurses should carry malpractice insurance and if you have more questions about that you should read this article.
Here are some tips that I have learned along the way and they have helped me avoid any problems with charting. Of course, you always want to check your hospital policies and protocols first, but here are the things I've learned that have helped me:
Always chart objectively. State the facts. Chart what you hear, see, smell and feel. Document what the patient is actually doing. Always use quotations when you are charting what the patient said and quote them verbatim.
I sometimes read what other nurses have charted and just cringe at the way they leave themselves wide open for a lawsuit. It's imperative that you understand what type of documentation can get you in big trouble. Don't chart "the patient is sleeping comfortably." How do you know this? When you went into that room what did you see? "Patient is sleeping comfortably, as evidenced by the patient lying quietly with eyes closed on her left side. Respirations regular in rate and rhythm at 14. No cyanosis or pallor and skin is warm dry. Patients said, "I'm going to take a nap because I'm tired." Do you see the difference? You have explained how you came to that conclusion. Don't leave any areas in your charting for misinterpretation.
Don't use words like "it appears", or "patient is anxious." Instead write "patient stated "I am anxious today." Her hands are trembling, and she is biting her fingernails. Patient verbalized concern about her family coming to visit today. Patient stated, "I'm worried about my family coming to see me because I haven't seen them in so long"
Never take shortcuts when you are assessing a patient. You shouldn't ever just peek your head in the door to check on a patient. Unless you physically examine the patient yourself, don't chart that you did. You need to check the patient thoroughly. Just because a patient "appears" to be sleeping, doesn't mean everything is okay. They may have pulled their IV out, or it could be infiltrated and because they're on pain meds and knocked out they don't feel it themselves. There could be a "code brown" under the sheets, and unless you lift the sheets to find out, you won't know.
If it "appears" that the patient is depressed, chart what makes your arrive at that conclusion. Are they crying? Flat affect? Refused their food? Chart what the patient tells you. "The patient stated " I want to die, I'm so depressed."
If a patient is angry and combative, chart everything that happened. Step away from your feelings about the incident, (I know this can be difficult), but you cannot chart with emotion. State what happened, objectively. "Patient clenched his fist and yelled at me saying, " hurry up and get his Dilaudid." Patient ripped his I.V out and threw the tubing on the floor, contaminating it." This leaves no room for misinterpretation and people will understand that this patient was obviously angry. Not because you said he was, but because of the way he was acting.
Never chart "pt.tolerated the procedure well." How do you know this? Did they tell you? If so, chart, "Patient tolerated the procedure well, as evidenced by patient stating "I feel so much better now that I have the catheter in" and "I'm so glad that it's over with."
If a patient falls, and you didn't witness it, don't say "patient fell." If you didn't see it, then you cannot state that it happened. Instead, chart, "patient found on the floor in the prone position and she stated "I tripped on the chair leg."
If an I.V site looks infiltrated to you, chart why you believe it to be infiltrated. "Patient's I.V is infiltrated as evidenced by I.V site redness, hot to the touch and patient stated "this is hurting me."
It's pretty simple when you break it down this way. It's just a matter of practice. When you chart, always imagine a judge and jury reading you work. Think before you chart and always take your emotions completely out of the picture. Also remember, if you don't chart it, it didn't happen. Always state facts and be truthful.
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