Defensive documentation: learn how good charting can protect you from liability.

When you document your nursing care in a patient's chart, you communicate with other members of the healthcare team and contribute to a legal document: the medical record.

What you write reflects the quality of your care. In a malpractice suit, good charting can be a primary defense. Careless, inaccurate, or incomplete charting can hurt you in court.

"In all of your charting, paint a picture of your patient so that others who read your notes will know what you saw and heard and did so they can compare that information with their own findings," advises Donna Middaugh, RN, MSN, Clinical Assistant Professor in the College of Nursing at the University of Arkansas for Medical Sciences in Little Rock.
 

Follow these fundamental principles:

  • Chart promptly. As soon as possible after you make an observation or provide care, document your action. Prompt charting encourages fresh, detailed notes. If you wait until the end of your shift, you could forget to include important information.
  • Keep it neat. You can't communicate properly if others can't read what you've written. Illegible handwriting wastes their time and could lead to a patient injury. If your handwriting is hard to read, print carefully. If you don't have enough room to write a legible message, place brackets around the blank section and write "See progress notes." Then document completely and neatly in the notes.
  • Write in ink. The medical record is a permanent document, so don't write in pencil. Use only black or dark blue ink to ensure legible photocopying. Avoid using a felt-tipped pen on multiple-page forms because the tip may not press hard enough.
  • Check spelling and grammar. Misspelled words and poor grammar make an unprofessional impression. To avoid errors, use a pocket dictionary and keep a list of commonly misspelled terms and medication names.
  • Use approved abbreviations. Unfamiliar or seldom-used abbreviations can confuse other caregivers and lead to potential patient injuries. Ask to see your facility's list of approved abbreviations. Familiarize yourself with them, and use them consistently.
  • Write clearly and concisely. Make sure each sentence has a subject. Strive to use short words in place of long ones. Avoid using words such as "appears" or "apparently" when describing signs and symptoms--they make you sound unsure of your observations.
  • Specify times. Chart exact times, especially when you document significant patient events, changes in condition, and nursing actions. Avoid entries such as "0700 to 1500" because they imply inattention to the patient.
  • Chart in chronological order. Patient improvement or deterioration is easier to spot when events are charted in the order they occur. If you wait until the end of your shift to record all your assessments, you may inadvertently omit important clues about your patient's condition. If you must delay documentation, keep a list of notes to expand on when you chart.
  • Be accurate, objective, and complete. Document what you see, hear, and do--opinions and assumptions don't belong. When documenting what your patient said, use the exact words, in quotation marks. Include data relating to all aspects of patient care and the nursing process.
  • Sign each entry. After recording information in the progress notes, sign your first name or initial, your last name, and your professional status (such as SN or RN).
  • Correct errors properly. If you make a mistake, draw a line through the incorrect information and write "mistaken entry." Add the correct information and an explanation on the next available line, and initial the changes. Never erase or scribble over an erroneous entry, which could appear like an improper cover-up if you were ever involved in a lawsuit.

 

A job well done

What you write in a patient's chart tells others about the nursing care you give. Proper documentation creates a lasting impression of a job well done.

Frequently Asked Questions

You have questions. We have answers. (It's why we're here.)



What kinds of activities might trigger a disciplinary action by a licensing board or regulatory agency? 


The fact is anyone can file a complaint against you with the state board for any reason—even your own employer—and it doesn’t have to be solely connected to your professional duties. All complaints need to be taken seriously, no matter how trivial or unfounded they may appear. 


How does a shared limit policy work?


A shared limit policy is issued in the name of your professional business or company. The policy provides professional liability insurance coverage for the business entity named on the certificate of insurance and any of the employees of the business entity, provided they are a ratable profession within our program. Coverage is also provided for locum tenens professionals with whom the business entity has contracted for services the locum tenens performs for the business entity.

The business, and all eligible employees and sub-contractors you regularly employ, will be considered when determining your practice’s premium calculation and share the same coverage limits you select for the business.


We have a shared limit policy. Are employees covered if they practice outside our office?


The policy covers your employees outside the office as long as they are performing covered professional services on behalf of your business.

If your employees are moonlighting, either for pay or as a volunteer, they should carry an individual professional liability insurance policy to cover those services. Otherwise, they might not be covered for claims that arise out of these activities.



There are plenty more where those came from.


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