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Should I Be Worried About My Charting?

The short answer is yes. But don’t worry, we’ve got some great tips to help you stand up in the courtroom without sacrificing patient care.

If you’ve ever been in a deposition (we’re sorry), you know that what you chart not only matters, but when you chart, how you chart, and how accurate the rest of the details are matter too.

It’s easy to feel like you are skipping out on patient care when you have to spend time charting, but skipping now might mean a whole bunch of heartache later. So what’s going to matter in the court of law?

The details and the timeline. The old adage “If you didn’t chart it, it didn’t happen” is true. If you can’t prove you did it, you won’t be very successful in claiming that you did. Many nurses instinctively chart the big stuff like cardiac arrests, patient falls, or change in condition. The problem is that most of those things aren’t singular events; they are a part of a timeline gone horribly wrong. In fact, 84% of patients experience signs of deterioration up to 24 hours before a cardiac arrest. You may have prevented a cardiac arrest or two in your career, but it isn’t the good outcomes you’ll get sued for. What about the ones you missed?

The client’s lawyer needs to prove one of a few things:

  • You weren’t qualified to do the job you were doing
  • You weren’t paying attention to warning signs
  • You did something wrong in your care or didn’t catch a mistake in someone else’s care
  • The overall care provided was negligent

Woah, you know the care you provided wasn’t negligent, but how do you prove that on paper? Documentation. That means documenting normal vital signs, bed baths, daily rhythm documentation, fall assessments, and pain management/reassessment. All that stuff your manager or quality person has been hounding the unit about.

You likely do all of those things for your patient, but if you can’t prove you did the bare minimum, it’s pretty easy to prove you didn’t provide stellar care. Once a jury thinks you don’t take great care of your patients it isn’t a far leap to assign blame.

There are some things you can do to protect yourself.

Chart everything that is mandatory. That suicide risk assessment is not only on The Joint Commission’s radar; it’s also a critical step in making sure your patient doesn’t do the deed on your watch.

Chart the normal AND the abnormal. If you have a tech/CNA/aide, it is still your job to review their work and make a call if something doesn’t seem right. Speaking of making the call, document when and who you talked to.

Don’t get sloppy. If you are missing words or spelling things wrong, it can be hard to regain respect in a courtroom. An incorrect VS in the chart is a terrible way to lose a lawsuit. Watch the details, and that includes the written information from people who report to you.

Do a thorough assessment and daily charting. If you drag and drop the same oxygen status, A&O, and wound drainage description as the nurse before you, you can bet the lawyer will mention that you didn’t do your own assessment at all. There is nothing wrong with charting what you see, but make sure you can speak to your own assessment.

Do your hourly rounding even if you have to stretch the number to 2 or 3 hours, depending on what kind of job you have. A simple, “patient resting in bed, TV on, declines the need for toileting at this time” is going to mean a lot to you when the patient tries to get up 15 minutes later and suffers a catastrophic fall.

Keep up with your certifications. That means your nursing license and whatever life support qualifications you require. If you can’t prove you were licensed to do CPR, there isn’t much hope that your charting will help after a bad arrest.

Here’s a big one. CHART AS YOU GO. Believe it or not, charting at the bedside is the most effective way to get work done.  Charting done in real-time is more accurate, promotes better communication among team members, and is safer for the patient. How can your doctor catch trending VS if you wait until the middle of your shift to add any? Did room 407 eat all of their Jello, or was that room 410? Your memory isn’t as good as you think it is.

Did your chest pain patient already get aspirin or should they get one now? How dangerous would it be to give them a double dose of their morning meds? By charting at the bedside, you can accurately capture what’s happening. Also, word to the wise, your electronic health record knows when you documented everything, even if you back-time the care provided. Of course, the lawyers can see this timeline, too, so don’t let hindsight influence your charting.

Finally, don’t make stuff up.  Yes, those respirations are probably 18, but the more you actually asses, the more likely you will catch a problem before it becomes a lawsuit.

Take our advice and “Dance like no one is watching, and chart like it may one day be read aloud in a deposition” -unknown.

PS. The dancing is probably on camera too. Save it for your living room!

 

 

Amanda Ernst, DNP, RN, CEN

Amanda Ernst, DNP, RN, CEN

Author

Amanda is an ER nurse with 10 years of healthcare experience. She currently works as a nurse educator and as an adjunct professor for several schools. She also works as a freelance healthcare writer in her spare time. Amanda thinks the greatest thing about nursing is the endless possibilities and opportunities to learn. What have you learned today?

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