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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.

 

 This publication is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. This information is provided for general informational purposes only and is not intended to provide individualized guidance. All descriptions, summaries or highlights of coverage are for general informational purposes only and do not amend, alter or modify the actual terms or conditions of any insurance policy. Coverage is governed only by the terms and conditions of the relevant policy. This information is not intended to offer legal advice or to establish appropriate or acceptable standards of professional conduct. Readers should consult with a lawyer if they have specific concerns. Neither Affinity Insurance Services, Inc., HPSO, nor CNA assumes any liability for how this information is applied in practice or for the accuracy of this information. 



Healthcare Providers Service Organization is a registered trade name of Affinity Insurance Services, Inc., a licensed producer in all states (TX 13695); (AR 100106022); in CA, MN, AIS Affinity Insurance Agency, Inc. (CA 0795465); in OK, AIS Affinity Insurance Services, Inc.; in CA, Aon Affinity Insurance Services, Inc., (CA 0G94493), Aon Direct Insurance Administrators and Berkely Insurance Agency and in NY, AIS Affinity Insurance Agency.​

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