avoiding legal pitfalls

8/3/2019 Avoiding Legal Pitfalls

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Charting defensively


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How to chart

What to chart

When to chart

Who to chart


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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 andbed 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.


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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.


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Use only approved abbreviations andexpress your observations in quantifiableterms.

Wrong: output adequate; Pt. Appears to be inpain Right: output 1200 ml; Pt. Requestedpain medication after complaining of lower

back pain radiating to his R) leg which he rated7 out of 10 on the visual analogue scale (VAS)


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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. Insertionsite. No drainage. Quarter-sized area of edemaabove insertion site, I.V. Removed, site cleanedwith povidone iodine and sterile dressing applied.

Warm compress applied to site x20 min. Dr. JohnSmith notified. Acetaminophen 650 mg given POat 1015. Pt now reports pain 0/10 on VAS. M.Doherty,RN


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Dont use language that suggests a

negative atttitude toward the patient. Ex:obstinate, obnoxious, drunk, bizarre or abusive.


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EX:I attempted to perform the daily abdominal dressing

change, but pt stated, this doenst need to bedone everyday. It doesnt hurt and I dont want you

to touch it. Leave me alone. I explained theimportance of monitoring and cleaning theincision and offered an analgesic to be given 20min before dressing would be chanegd. Pt. Became

agitated and still refused. Dr. B. Humbert notifiedthat incisional site was not assessed nor wasdressing changed and that patient was agitated.


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Significant situations out-of-the-ordinarysituations, critical situations.

Chart complete assessment dataDuring initial assessment, focus on the

patients reason for seeking care, and thenfollow up on all other problems hementions. Be sure to chart everything youdo as well as why.

Document discharge instructions.


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Document nursing care when youcomplete care or shortly afterward.

Never document ahead of time yournotes will be inaccurate and youll leave

out information about the patients

response to treatment.


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Never ask another nurse to complete yourcharting (and never complete anothernurses charting).

If the other nurse makes an error ormisinterprets information, the patient canbe harmed.

Delegated charting destroys the credibilityand value of the medical record both in thefacility and in court.


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Dont record staffing problemsDont record staff conflicts.Dont mention incident reportsDont use words associated with errors (i.e:

by mistake, accidentally, somehow,unintentionally, miscalculated and confusing)

Dont name a second patient. (Use ptsinitials, room and bed number or the word

roommate)Dont chart casual conversations with

colleagues.


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

avoiding legal pitfalls

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