Clear, accurate, and accessible documentation are essential elements of safe, quality, evidence-based nursing practice. Proper documentation of work is critical for effectively communicating with each other and results in higher patient care quality.
Ensure all documentation is complete, correct, and timely. Sloppy documentation practices can be used against an Healthcare Professional in a malpractice lawsuit. Here are some helpful tips for aceing your charting practice:
Charting Do's for Health Care Providers
- Before entering anything, ensure the correct chart is being used
- Ensure all documentation reflects the full extent of your professional capabilities
- Always use complete descriptions
- Chart the time medication was administered, the administration route, and the patient's response
- Chart precautions or preventative measures used, such as bed rails
- Record any phone call to a physician, including the exact time, message, and response
- If a patient refuses to allow a treatment or take medication, document it and be sure to report to a manager and the patient’s physician
- Always chart patient care at the time you provide it; it is too easy to forget details later on
- If something needs to be added to documentation, always chart that information with a notation that it is a late entry and include the time and date
- Document often and with enough detail to tell the entire story
Charting Don'ts for Health Care Providers
- Do not chart a symptom such as “c/o pain,” without also charting how it was treated
- Never alter a patient’s record - that is a criminal offense
- Do not use shorthand or abbreviations that aren't widely accepted
- Do not write imprecise descriptions, such as "bed soaked" or "a large amount"
- Do not chart excuses, such as "Medication not administered because it wasn’t available"
- Never chart what someone else said, heard, felt, or experienced unless the information is critical. If absolutely needed, use quotations and properly attribute the remarks
- Never chart care ahead of time, as situations often change and charting care that has not been performed is considered fraud
While charting may seem like a menial and repetitive task, demanding the highest quality of patient documentation protects yourself from accusations of malpractice and ensures proper patient care is satisfied.