John Wooden said that “It’s the details that are vital. Little things make big things happen.” In health care, details are literally vital because they impact a patient’s life. For nurses, such details come in the form of charting and little mistakes can make big legal problems happen.
In this blog, I will review the importance of clear, concise, accurate, and timely charting, charting pitfalls to avoid, and good charting practices so that you can both safeguard patients and protect yourself from potential liability.
The Importance of Charting
As a member of the nursing profession, you must ensure that charts present an accurate, clear, and comprehensive picture of a patient’s needs, your actions and interventions, and the outcome. An exemplary chart will:
- Reflect a patient’s perspective;
- Communicate pertinent information to all health care providers;
- Show your application of knowledge, skill, and judgment;
- Demonstrate safe and ethical care; and
- Comply with legal obligations and practice standards.
From a legal perspective, it is critical that your chart satisfies the above in order to establish that you met the standard of care of a reasonable prudent nurse. A court will review a nurse’s chart to reconstruct critical events, establish time frames, and refresh the memories of witnesses. If you undertake an action or intervention, but fail to chart it, a court may infer that the action or intervention was not performed. Needless to say, such omissions can significantly undermine the strength of your defence.
Charting Pitfalls to Avoid
There are a number of charting pitfalls which you can avoid. Below is a chart of such pitfalls and the proactive steps to avoid them:
- Omitting relevant health or drug information
- Inquire about a patient’s food and drug allergies, diseases, and chronic health issues.
- Comply with hospital policy with respect to flagging or highlighting drug allergies
- Failing to note action, intervention, or medication
- Record every action, intervention, and medication in real-time
- For medication, note the dose, route, and time
- Recording information on the wrong chart
- Assign a different nurse to each patient
- Double-check patients’ wristbands
- Failing to note a discontinued medication
- Cross-reference the doctor’s orders with the patient’s medical information
- Failing to document drug reactions or changes in patient’s condition
- Closely observe patients
- Consider the potential of an adverse reaction to medication when a patient reports a change in symptoms
- Writing illegible or incomplete records
- Print, do not write, notes
- Be diligent in completing all documentation
Good Charting Practices
Some good charting practices to keep in mind include, but are not limited to:
- Document, record, and note in real-time;
- Print your notes rather than use handwriting;
- Complete charts in full compliance with legislation, regulations, and practice standards;
- Do not use personal or unapproved abbreviations;
- Review and proofread your notes; and
- Chart with a view to ensuring that the reader would understand that the patient received adequate and appropriate care and that your actions were reasonable and prudent.
Remember that when it comes to charting, the little things make big things happen with respect to patient care and professional liability.
Renée Vinett is a former registered nurse with over 25 years of experience in disability management in the U.S. and Canada. If you have any problems or questions, feel free to contact her at 416-361-7560 or firstname.lastname@example.org.