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.

[Lennonninja, MSN, APRN, NP]

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

[DalekRN]

I often will chart conversations in a brief way- "found mother sleeping with infant, awoke pt and encouraged/reviewed safe sleep, placed infant in bassinet per mom request" or "mom reminded about safe sleep, declines and chooses to sleep with baby in bed with her" or "pt declined stronger pain meds" or "informed pt to call out for getting up the first time" and I chart that SCDs are on each time i round and readings from continuous pulse ox, etc. I have quickly noted "charge nurse informed/in to see pt"as well. Chart to a jury- paint a picture of your shift.

[emtb2rn, BSN, RN, EMT-B]

I also chart conversation from rounding. I chart verbatim responses from docs. Strive for consistency, show a pattern of thorough documentation. And yeah, it's cya.

[jadelpn, LPN, EMT-B]

IF your hospital policy states that you are bound to make a charge nurse aware of something (ie: when your patient is to be transferred off of the floor, for instance) then make sure you document when you do so. ie: 1400: MD order for patient transfer to ICU. Informed charge nurse XYZ, RN of same. HoneyBeGood, RN----------------------------------------------------------------------------------------------

[Esme12, ASN, BSN, RN]

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

[psu_213, BSN, RN]

I almost never chart that I notified the charge nurse. I will notify him/her of a difficulty pt, a possible ICU transfer, if the pt is going off the floor for some reason, etc...I notify them for patient flow reasons, and this is not really something that needs to be charted.

[NicuGal, MSN, RN]

Actually, if you are leaving the floor with the patient, you do need to chart who you reported to about your other patients. If it routine flow, then no, it doesn't have to be charted. When following the chain of command, always chart chart chart.

[jadelpn, LPN, EMT-B]

I almost never chart that I notified the charge nurse. I will notify him/her of a difficulty pt, a possible ICU transfer, if the pt is going off the floor for some reason, etc...I notify them for patient flow reasons, and this is not really something that needs to be charted.

It is, however, if it is in fact POLICY that charge nurse be notified of a transfer. It is the "if it is not charted, it is not done" scenario.

[nurseprnRN, BSN, RN]

The bit about, "Chart for the jury" is helpful if it gets you to close your eyes briefly and envision what your notes must show to someone who wasn't there and needs to know what happened.

Furthermore, a legal nurse consultant will likely review your notes before any jury ever sees them. S/he will very likely have background in your specialty, if indicated, and at least with the applicable standards of care. Therefore, leaving things out will raise the question in his/her mind, "How come somebody did / didn't do this?" in a way that won't occur to the attorney. Then you may find your notes being more important that you envision, even if the issue isn't one of nursing malpractice itself.

[psu_213, BSN, RN]

It is, however, if it is in fact POLICY that charge nurse be notified of a transfer. It is the "if it is not charted, it is not done" scenario.

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.

[NicuGal, MSN, RN]

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.