Charting defensively

How

to chart to chart to chart

What

When Who

to chart

 Stick

to the facts

Recard only what you SEE, HEAR, SMELL,

FEEL, MEASURE AND COUNT NOT what you infer, conclude, infer or assume. For example: if a patient pulled out his I.V line but you didnt witness it, write: Found pt, arm board and bed linens covered with blood. I.V line and venipuncture device were untaped and hanging free. If the patient says he pulled out his I.V. Line, record that.

 Objectively

describe patients behavior:

Pt found pacing back and forth in his room, muttering

phrases such as, Ill take care of him my way while punching one hand into the other.
Avoid

using expressions such as appears spaced out, flying high, exhibiting bizarre behavior, or using obscenities.

 Use

only approved abbreviations and express your observations in quantifiable terms. Wrong: output adequate; Pt. Appears to be in pain Right: output 1200 ml; Pt. Requested pain medication after complaining of lower back pain radiating to his R) leg which he rated 7 out of 10 on the visual analogue scale (VAS)

 Ex:

Complaining of pain at L) antecutital I.V. Site at 1000. Pain rated on VAS scale 3/10. Dressing removed. Redness 2 cm wide around I.V. Insertion site. No drainage. Quarter-sized area of edema above insertion site, I.V. Removed, site cleaned with povidone iodine and sterile dressing applied. Warm compress applied to site x20 min. Dr. John Smith notified. Acetaminophen 650 mg given PO at 1015. Pt now reports pain 0/10 on VAS. M. Doherty,RN

 Dont

use language that suggests a negative atttitude toward the patient. Ex: obstinate, obnoxious, drunk, bizarre or abusive.

 EX:

I attempted to perform the daily abdominal dressing change, but pt stated, this doenst need to be done everyday. It doesnt hurt and I dont want you to touch it. Leave me alone. I explained the importance of monitoring and cleaning the incision and offered an analgesic to be given 20 min before dressing would be chanegd. Pt. Became agitated and still refused. Dr. B. Humbert notified that incisional site was not assessed nor was dressing changed and that patient was agitated.

 Significant

situations out-of-the-ordinary situations, critical situations.

Chart

complete assessment data During initial assessment, focus on the patients reason for seeking care, and then follow up on all other problems he mentions. Be sure to chart everything you do as well as why. Document discharge instructions.

 Document

nursing care when you complete care or shortly afterward. document ahead of time your notes will be inaccurate and youll leave out information about the patients response to treatment.

Never

 Never

ask another nurse to complete your charting (and never complete another nurses charting). If the other nurse makes an error or misinterprets information, the patient can be harmed. Delegated charting destroys the credibility and value of the medical record both in the facility and in court.

 Dont Dont Dont Dont

record staffing problems record staff conflicts. mention incident reports use words associated with errors (i.e: by mistake, accidentally, somehow, unintentionally, miscalculated and confusing) Dont name a second patient. (Use pts initials, room and bed number or the word roommate) Dont chart casual conversations with colleagues.

 Lippincott

Williams and Wilkins. (2006). Charting made incredibly easy (3rd ed.). Philadelphia, PA: Author