Proper Charting for Nurses and Other Health Care Professionals

In today’s highly litigious society a nurse must keep basic principles in mind in order to prevent litigation for both the institution he or she works at and for the nurse him/herself.

The following are some tips to keep in mind when charting. These are not all inclusive but they do provide a general guideline for the nurse and other health care professionals.

  1. Keep in mind that juries rely heavily on nurse charting. They consider the chart the most reliable source of information to determine what happened. If you chart properly, your chances of winning a lawsuit are better. Proper charting means that you do not alter or go back and correct documentation. Remember the proper method is to draw a line through improper or incorrect charting and place the word “error” immediately after the entry with your initials. If an attorney attempts to impeach your credibility this will only help you at the deposition or if you have to testify live at trial.
  2. Follow these rules for charting
    1. chart everything
    2. include observations,
    3. nursing actions,
    4. patient’s response to therapy and treatment,
    5. any unusual incidents or omitted treatments
    6. safety precautions you took to protect the patient
    7. your attempts to reach the doctor
    8. any reservations you have about a doctor’s orders
    9. the date and time of each entry
    10. the patient’s name and identification number off the chart
    11. your signature on each entry (when in doubt chart everything)
    12. leaving blanks or omitting documentation could have disastrous results in a lawsuit
  3. Do not chart subjective opinions, just facts- document only what you observe with all your senses. Be specific: avoid being general or vague. Subjective opinions leave the nurse open to questions about his or her credibility and consistency in charting. A plaintiff attorney’s best case scenario is when a nurse charts with the mindset of criticizing preceding shifts or using the chart as a medium for making disparaging or hurtful remarks regarding the institution and its policies. The proper channels for verbalizing and documenting dissatisfaction with the “system” should be used. Otherwise the nurse may be construed as a disgruntled employee and a witness who lacks credibility.
  4. Be accurate: being inaccurate diminishes the strength of your case. Jurors do not look kindly upon errors and view it as sloppiness on the part of the licensed person. If you have poor handwriting print in block letters. This will enhance the readability of your documentation. Do not document entries that are boilerplate language if this documentation is not clear, i.e.: “call bell within reach, verbalizes no complaints” when the patient is in an obtunded or comatose state! This merely provides fuel to the fire to demonstrate that the nurse was sloppy and documented generic boilerplate language and did not properly assess the patient.
  5. Do not obliterate an entry. The obliteration of any entry will only provide more ammunition for the plaintiff attorney. The altering of the chart in any manner is usually construed in favor of the plaintiff/patient who is bringing the lawsuit. In some instances this may be considered fraud and will subject the institution and you to civil and criminal penalties.
  6. Chart as you go. This is easier said than done. Nurses are extremely busy. However, you must jot down the briefest of notes even in an imminent emergency in order to preserve the accuracy and credibility of the record. Charting varies, but most institutions mandate minimum charting of every 1-2 hours and more frequently depending on the environment (i.e., PACU, ER, ICU settings). Use your best judgment and if worse comes to worse set up a sheet that has a slot for vital signs and quick entries for any change in the patient’s condition.
  7. If you observe changes in the patient, do not just chart them, but also notify the physician. This is a frequently litigated area. The nurse exposes him or herself to litigation when a physician is not alerted to changes. The physician will certainly not stand by the institution or the nurse if the physician is placed in the position of fingerpointing. If you are dealing with an irate or difficult physician document your assessment and nursing process and notify your supervisor. If you are the supervisor, continue to document calls made. One irate physician is not worth you losing your license over. If the physician becomes abusive or does not respond appropriately, notify the proper administrative personnel to assist in resolving the matter.
  8. If you make a mistake in charting-correct it after the last entry you made-not where you should have made it in the first place. This rule cannot be stressed enough. A plaintiff attorney will use this as another way to establish that a “cover up” was taking place. The entry will be invariably construed in the best case as careless and sloppy or in the worst case as deliberate.
  9. If you are asked to chart for someone else don’t do it. But if you are unable to refuse, include the name of the person you are charting for. Then sign your name. The signing of any document for anyone is strongly frowned on. See Number 8.
  10. Above all, do not try to cover up a mistake. Be candid with both family, physician and your institution. Your credibility is everything. Once you have the reputation of covering up errors the level of trust that is needed in the health care profession is undermined and your reputation as a professional may be irreversibly damaged.

These basic principles should decrease the nurse’s chance of being named in a lawsuit and decrease the chance of a bad outcome.

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