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Documentation Do's and Dont's​​​​

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 to help improve your charting:


Do

  • Check that you have the correct chart before you write.
  • Chart a patient's refusal to allow treatment or take a medication. Be sure to report this to your manager and the patient's physician.
  • Write "late entry" and the date and time if you forgot to document something. 
  • Write often enough to tell the whole story.
  • Chart preventive measures, such as side rails.
  • Chart contemporaneously (contemporaneous notes are credible).
  • Write legibly, offering concise, clear notes reflecting facts.
  • Chart what you report to other healthcare providers.
  • Chart solutions as well as problems.
  • Document your observations. Write only what you see, hear, feel, or smell.
  • Encourage others to document relevant information that they share with you.
  • Document circumstances and handling of errors.
  • Chart your efforts to answer your patients' questions.
  • Chart patient/family teaching and response.

 

Don't

  • Chart a verbal order unless you have received one.
  • Chart a symptom (for instance: c/o pain), without also charting what you did about it. Wait until the end of the shift and rely on memory.
  • Ever alter a record. If you make an error, do mark through it with one line, indicate you are making a correction, and initial (or sign) and date.
  • Document what someone else said they heard, saw, or felt (unless the information is critical--then quote and attribute).
  • Write trivia: "a good shift." (What does that mean?)
  • Be imprecise. Avoid terms like "large amounts" and "appears."
  • Write your opinions, such as that the patient is fat or lazy.
  • Blanket chart or pre-chart. It is considered fraud to chart that you've done something you didn't do.

 

 

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