Anyone know of ways to learn more about defensive charting?

[Guest716906]

Hello,

I am realizing as the years go by that we learned nothing about court/defensive charting/legal issues in nursing school. I used to chart the relevant information on patients and focused assessments. As the years go by, I have been dinged for charting, and managers are adding more and more little random things we "have to chart." I am wondering if I have been doing it wrong all along. I am getting confused on what is important to chart/ what would protect me in court. Does anyone know of classes/educators that can help me with this.

[Koalified]

What I learned in nursing school is what I still do today. Just state the facts. Not opinions, not recommendations. Just the facts. Don't use the word "appears" as in "the pt appears to be drug seeking and would benefit from a psych consult". We are not paid to diagnose pts. I would write "pt is laughing and talking on the phone and rates her pain 10/10. Pt sets her alarm clock and asks for pain med q2hrs. Pt states only dilaudid works for her pain".

As for mgmt asking for more and more, my thought is that I document for the courts, not for mgmt. If something is in my flowsheet, I'm not going to write a note about it. You can write something like " VSS, see flowsheet".

[nurse lala, BSN, RN]

What first came to mind reading your question, is that Admin is communicating changes in rules or regulations. Every year JC further refines safety indicators. And we refine policy and procedures as indicated. But you infer that the new charting expectations are irrelevant. Please can you list some of these things you are directed to chart?

And I agree with our colleague Koalified that you are allowed to refer the reader to another part of the medical record if already documented. With reservations. So in the case of a Complicated situation I will narrate a timeline of events and include vital data already documented elsewhere, because I want to make sure the reader understands the full narrative of what occurred. That's defensive writing for court.

[brownbook]

There are two issues. Insurance reimbursement and what might happen in a malpractice law suit.

The whole issue is a big bloody mess. You will read opposing opinions from everyone.

How often a problem even arises is another issue. I've never been contacted by a lawyer about a lawsuit. I've never been told by management that I need to chart, or not chart, anything.

It would be nice if your management or nursing education department would in-service you once a year and explain the why's behind "random things" they want you to chart.

[TruvyNurse]

Chart to cover your butt. Always chart how you kept the patient safe, ALWAYS continuing to monitor patient, rounds etc. Chart the facts

[JBudd, MSN]

I did a course (workbook) on charting, 30 ceus, I think it was through Western online schools. Had some really interesting stuff to say (and not say).

It's called Charting for Nurses: How and What to Document

[Meriwhen, ASN, BSN, MSN, RN]

As for mgmt asking for more and more, my thought is that I document for the courts, not for mgmt. If something is in my flowsheet, I'm not going to write a note about it. You can write something like " VSS, see flowsheet".

That's how I approach it. I chart as though a lawyer is going to read it out loud in a courtroom. If it sounds like I'm spelling things out...well, I am.

I also write things out instead of abbreviations, so there's no question in anyone's mind about what "QHS" or "AO3" mean. It makes for longer notes...but on the upside, my typing speed has improved to about 80 WPM.