Defensive/CYA charting

[HoneyBeGood]

Hi guys,

I am a year into this field working in the hospital. my concern is charting and what you MUST always make sure you document on.

I know to document my assessments, change in status, calling the doctor, etc. I did not realize that I needed to chart every time I informed my charge nurse of something. This was not emphasized during my orientation in the hospital. Mainly Physician contact.

But what things should nurses ALWAYS make sure they chart on? I wish in nursing school they had given us a topic or course on defensive charting. I want to protect my license, but I am knew and there is still a lot I don't know.

Your advice is greatly appreciated.

[jadelpn, LPN, EMT-B]

Let me put it this way...my pt is going downhill quickly. In the midst of getting a ABG, getting the correct medication, talking to doctors, calling an RRT, charting all that...charting "charge nurse notified" is very low on my list of priorities.

And hence why the OP is being called into a possible disciplinary meeting, per her other thread.

[jadelpn, LPN, EMT-B]

It is not a policy where I work...usually the charge nurse knows before we do that the patient is being transferred. It may be the policy for your institution.

Apparently, this is policy where the OP works, from another posting regarding this situation.

[psu_213, BSN, RN]

And hence why the OP is being called into a possible disciplinary meeting, per her other thread.

Well, if it is facility/unit policy to chart this, then chart it. However, that is not an issue that should have been addressed in school, as I have never encountered such a policy. My guess is, there is probably more to this disciplinary meeting that just the OP's having forgot to chart "charge nurse notified."

[jadelpn, LPN, EMT-B]

Well, if it is facility/unit policy to chart this, then chart it. However, that is not an issue that should have been addressed in school, as I have never encountered such a policy. My guess is, there is probably more to this disciplinary meeting that just the OP's having forgot to chart "charge nurse notified."

Here's the thing. If there is a policy at a facility that states as part of a nurse's responsibility is to notify a charge nurse of something--anything--then the only way to ensure that you did what policy mandates that you do is to chart it.

I am not suggesting that it is the be all and end all during a RR or code, however, if it is something that a facility mandates that a nurse do, then chart it.

Otherwise "well I DID tell charge" is not a plausible answer.

[turnforthenurse, MSN, NP]

Otherwise "well I DID tell charge" is not a plausible answer.

Charting "charge nurse notified" is a plausible answer.

Just as others have mentioned, if it is a written policy at your facility that a charge nurse must be notified for [whatever], then you need to chart it. Period.

I always chart when I notify the MD of something and what the outcome was. If I have notified the MD of something a few times and nothing is being done, I will tell the charge nurse and chart "charge nurse notified of [whatever]." Always CYA.

[MunoRN, RN]

Here's the thing. If there is a policy at a facility that states as part of a nurse's responsibility is to notify a charge nurse of something--anything--then the only way to ensure that you did what policy mandates that you do is to chart it..

Just as others have mentioned, if it is a written policy at your facility that a charge nurse must be notified for [whatever], then you need to chart it. Period.

I've never heard that every instance of compliance with policy requires that it specifically be charted. It's policy pretty much everywhere to perform hand hygiene going into and out of every room, I've never seen any place that charts the many times this happens per shift.

[NicuGal, MSN, RN]

Side note: Make sure you document names, not just charge nurse. I have been including involved in 2 cases that did not have names documented. The prosecuting attorney loved it.

[mind_body_soul RN]

Never chart "patient found...", that implies they were lost. Also don't chart that somebody fell unless you witnessed it.

Never chart that an incident report was completed.

Never chart opinions, just facts. Chart what you see and do. If you have to report what someone else said, write: "Per CNA Mary, patient refused to get out of bed x 3 attempts." Or "Patient's daughter reports patient has been increasingly confused and combative x7 days"

Or even better, put what the patient, family, or doctor said in quotes.

Be descriptive. Chart behaviors and quotes to back up your assertions (how were they verbally abusive? What was said?)

If the patient complained of pain, SOB or anything else, chart what you did about it and their response.

Chart your safety interventions.

Chart patient education and response.

I work in LTC, so if something happens or changes I always chart "Notified Dr. So-and-So, family/POA, and DON."

If I notify a physician about something and no new orders are received , I chart that too.

Your charting should show that you are a prudent and attentive nurse that is following the standards of care as well as the policies and procedures of your facility.

[ParisAntonel]

http://www.nsna.org/Portals/0/Skins/NSNA/pdf/Documentation%20Avoiding%20Malpractice%202010.pdf

This is so helpful, I love it, thank you! Time for me to improve my charting skills.

[nurseladybug12]

I document on fall risk scores as required, when pts leave the floor and when they return, because you never know what can happen when they are not on the floor, and sometimes the dr hasnt allowed them to leave but they choose to do so anyways, ie when they are on bleeding precautions and they choose to drag their hep gtt with them! ugh. So I always chart on things pts do that is against the better judgment of healthcare personnel and make sure to include that they were educated on this and that, verbalize understanding, but do x,y and z instead.

[ArtClassRN, ADN, RN]

If you have to fill out an incident report for any reason, don't mention it in your charting!

This is pretty much the ONLY think they tell us in school.

OP, just use your head and chart according to patient needs.