Do's and don'ts of documentation.

Good documentation can help you defend yourself in a malpractice lawsuit, and it can also keep you out of court in the first place.

You have to make sure it's complete, correct, and timely. If it's not, it could be used against you in a lawsuit. Here are some tips that may help you improve your charting:
 

Do's

  • Check that you have the correct chart before you begin writing. Make sure your documentation reflects the nursing process and your professional capabilities.
  • Write legibly.
  • Chart the time you gave a medication, the administration route, and the patient's response.
  • Chart precautions or preventive measures used, such as bed rails. Record each phone call to a physician, including the exact time, message, and response.
  • Chart a patient's refusal to allow a treatment or take a medication. Be sure to report this to your manager and the patient's physician.
  • Chart patient care at the time you provide it.
  • If you remember an important point after you've completed your documentation, chart the information with a notation that it's a "late entry." Include the date and time of the late entry. Document often enough to tell the whole story.

 

Don'ts

  • Don't chart a symptom, such as "c/o pain," without also charting what you did about it.
  • Don't alter a patient's record--this is a criminal offense.
  • Don't use shorthand or abbreviations that aren't widely accepted.
  • Don't write imprecise descriptions, such as "bed soaked" or "a large amount."
  • Don't give excuses, such as "Medication not given because not available."
  • Don't chart what someone else said, heard, felt, or smelled unless the information is critical. In that case, use quotations and attribute the remarks appropriately.
  • Don't chart care ahead of time--something may happen and you may be unable to actually give the care you've charted. Charting care that you haven't done is considered fraud.

Read more about how you can earn six continuing-education contact hours, plus a 10% non-cumulative premium credit for 3 consecutive years on your professional liability insurance policy offered through NSO.

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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