Good Charting Can Reduce Nursing Liabilities. Here are 5 Tips to Keep in Mind.
Did you give Mr. Jenkins his medication at 1:20 p.m. or 1:40 p.m.? Does Mrs. Gershon have a latex allergy? What was Timmy’s temperature the last time a nurse did rounds? You’ll find all this information and more in each patient’s chart, and it’s standard procedure for every nurse to chart religiously any time they tend to a patient. But that doesn’t stop errors from arising. Just because there’s information in a patient’s chart doesn’t make it accurate.
Charting well is necessary for patient safety
Charting is a crucial component of patient care. It allows every member of the team to stay up to speed on the services patients have received. Thorough, accurate, and organized charts provide information, and help nurses and doctors interpret and act on that information to give patients what they need. Nurses must chart any administered medications, procedures, test results, and even provider-patient interactions to ensure an accurate log of care during a patient’s stay.
Today, digital charting is the standard at most facilities. Electronic medical records (EMR) make charting faster and simpler for nurses. EMRs can alleviate confusion and provide a more comprehensive overview of the patient’s care.
Unfortunately, when charting is not done well, it can be disastrous for both the patient and the healthcare provider. Inaccurate, incomplete, or unclear charting can lead to mistakes in patient care. For example, if a nurse forgets to note the results of a test, the patient may need to undergo the same test again. Or, if the chart lists a medication administered at 1:00 p.m. but it was really given at 2:00 p.m., the patient might receive their next dose too soon and suffer the effects.
Not only are these things dangerous to patients’ health and safety, but they can open the door for complaints, malpractice claims, and lawsuits that could cost someone their job or harm the hospital’s reputation.
Five charting tips for all nurses
To minimize charting liability and ensure the highest quality of patient care, nurses must develop good charting habits for completeness and accuracy. Here are five tips to help build good habits.
- Document in real time: Delaying documentation — or worse, documenting in advance — could lead to inaccuracies or omissions in information. To ensure the chart is accurate and thorough, make an effort to chart in real time or immediately after the patient interaction.
- Use precise, objective language: Be careful when using subjective words or phrases that could be interpreted broadly. Swap these terms and vagaries with specifics that leave no room for misinterpretation.
- Document refusals: If a patient refuses to comply with a medical directive, such as a medication or an exam, document the refusals in their chart. This records the attempts at patient care and negates potential negligence.
- Avoid leaving blanks: Regardless if you’re charting on paper or electronically, there may be sections or questions that do not apply to your patient. In these cases, use “N/A” instead of leaving the area blank.
- Follow error correction procedures: If there’s an error in a patient’s chart, correct it in accordance to your hospital’s requirements. Failing to correct a chart could lead to more confusion or increase charting liability.
By paying attention to charting practices and building good habits, nurses set themselves and their patients up for wellness and success.