To chart, or not to chart

'If in doubt chart' is what I was always taught, that and 'If it's not written it didn't happen.'

You have every right to record who you notified in the chart, by the sounds they're just trying to keep themselves out of any accountability so the hail will fall on your head not theirs. I'd just keep charting and if confronted on the issue, I'd just say I'v charted as I've been trained to as a nurse. Unless there's a policy for this then I have to say what happened and the outcomes or my license is in trouble.

And I bet there will never be a policy, as that can easily be sent to the BON and have legal action. They might get grumpy but I'm certain they can't force you to change your charting, you could take any write up they try for that reason further.

I guess I advise to always chart, as you work so hard to get your registration it's not worth putting it in danger. I'd want to change jobs if possible over agreeing to that.

I always chart that XYZ was an issue, that I did ABC, issue not resolved, contacted in-house RN supervisior and informed super of the issue and my actions to resolve.

I also chart that the super was notified about a patient..regardless of whether or not my actions resolved the issue. In my facility, anything we are going to put into our shifts report to the next, the super must be notifed within a reasonable amount of time.

In my eyes, if I didn't chart that i informed the super, then it appears that I did nothing about an issue/problem/incident that I could not resolve on my own..and just left it the way it was..say something happens and the patient is affected, then it falls into my lap, because hey, you didn't inform the super who could have intevened and perhaps the pt would not have suffered the consequences of your non-action..Not cool!

I chart what happened and who I spoke to. Period. Nobody's getting a free ride on my watch.

NOBODY can tell me NOT to chart something! PERIOD!!!!

Hmmmm...kinda makes you wonder why this policy was instituted in the first place, doesn't it?!?

So let me make sure I have this correct, because I am an airhead and get confused easily. You were told by your managers that if something untoward occurs that you as a nurse cannot or should not take care of yourself per policy, you should:

A. Report the event to whomever is in charge at the time but only verbally, not in writing

B. You are now being instructed NOT to document that you followed procedure by alerting 'the boss', thus have no way of proving that you did, in fact, follow procedure by relaying the event.

My first reaction is that something STINKS...and the odor kind of reminds you of being in a large open pasture where you have to watch out for used food from large male bovines.

So here these managers sit, and with a straight face have the gall to tell you NOT to chart that you followed policy by contacting/alerting them regarding an event? Seriously? Are the managers RNs with a current license? Why is it that they can't be involved in any care whatsoever? Hmmmm....

Do you have a Risk Management department? I am curious as to what they think of this policy.

I see your dilemma. If you continue to chart (as I would) that you contacted a manager regarding an event, your chart might be reviewed by one of these managers. If you report off to a snarky nurse that sees your (now forbidden) documentation, they might strut right to the manager's office with chart in hand. You might get written up or even fired for not following policy.

On the other hand, if a lawsuit were filed as the result of this event, the lawyers have no choice but to use the documentation as proof.

Lawyer: "Nurse X, Pt Y was under your care on August 13, 2011 during the hours of 0700 to 1900 when this incident occurred, correct?"

You: "Yes, she was."

Lawyer: "Why is it that you did not contact your supervisor to alert them to this incident? Did you feel that you were capable of handling this incident on your own, despite the clearly written policy that expressly prohibits your doing so?"

You: "Of course not! I contacted my supervisor! We were told that we couldn't document the fact that we alerted the management team. We were instructed to inform them verbally."

Lawyer: "Right. So you have no way of proving that you contacted your manager. My wife is a nurse, and she always tells me that 'if it isn't documented, it wasn't done!' Did you not learn this very basic responsibility in nursing school?"

You: "Yes, I did. I document EVERYTHING, just as I always have. But the managers told us specifically NOT to chart that any other person from management was involved in any care. I was following policy."

Lawyer: "You just stated that you document EVERYTHING. You did not document the fact that you sought the guidance of your manager regarding this event, which caused great harm to my client. Since you cannot prove that you did, in fact, alert your manager about this event, and you admitted under oath that you document everything, the only logical conclusion is that you failed to follow policy."

Scary, huh? I say DOCUMENT! You can always find a new job, but risking your license is out of the question.

Gotta tell you, I sat on a jury and listened to an officer give a description of what happened with the guy he arrested. He stated that he was weaving across both lines, strong odor of alcohol in the police car and that suspect slurred his words. In his arrest report no mention of anything except he crossed one line. Could not get the "if it isn't charted, it didn't happen" out of my brain. i trusted the report more than the actual testimony. (especially when another cop confirmed the report). ALWAYS chart when you notify someone. If I get a critical lab, page an MD and they don't call back, I page them again but I write "no return call, paged again" in the chart. No way is my license going for someone else!

Hmmmm...kinda makes you wonder why this policy was instituted in the first place, doesn't it?!?

So let me make sure I have this correct, because I am an airhead and get confused easily. You were told by your managers that if something untoward occurs that you as a nurse cannot or should not take care of yourself per policy, you should:

A. Report the event to whomever is in charge at the time but only verbally, not in writing

B. You are now being instructed NOT to document that you followed procedure by alerting 'the boss', thus have no way of proving that you did, in fact, follow procedure by relaying the event.

My first reaction is that something STINKS...and the odor kind of reminds you of being in a large open pasture where you have to watch out for used food from large male bovines.

So here these managers sit, and with a straight face have the gall to tell you NOT to chart that you followed policy by contacting/alerting them regarding an event? Seriously? Are the managers RNs with a current license? Why is it that they can't be involved in any care whatsoever? Hmmmm.

Do you have a Risk Management department? I am curious as to what they think of this policy.

I see your dilemma. If you continue to chart (as I would) that you contacted a manager regarding an event, your chart might be reviewed by one of these managers. If you report off to a snarky nurse that sees your (now forbidden) documentation, they might strut right to the manager's office with chart in hand. You might get written up or even fired for not following policy.

On the other hand, if a lawsuit were filed as the result of this event, the lawyers have no choice but to use the documentation as proof.

Lawyer: "Nurse X, Pt Y was under your care on August 13, 2011 during the hours of 0700 to 1900 when this incident occurred, correct?"

You: "Yes, she was."

Lawyer: "Why is it that you did not contact your supervisor to alert them to this incident? Did you feel that you were capable of handling this incident on your own, despite the clearly written policy that expressly prohibits your doing so?"

You: "Of course not! I contacted my supervisor! We were told that we couldn't document the fact that we alerted the management team. We were instructed to inform them verbally."

Lawyer: "Right. So you have no way of proving that you contacted your manager. My wife is a nurse, and she always tells me that 'if it isn't documented, it wasn't done!' Did you not learn this very basic responsibility in nursing school?"

You: "Yes, I did. I document EVERYTHING, just as I always have. But the managers told us specifically NOT to chart that any other person from management was involved in any care. I was following policy."

Lawyer: "You just stated that you document EVERYTHING. You did not document the fact that you sought the guidance of your manager regarding this event, which caused great harm to my client. Since you cannot prove that you did, in fact, alert your manager about this event, and you admitted under oath that you document everything, the only logical conclusion is that you failed to follow policy."

Scary, huh? I say DOCUMENT! You can always find a new job, but risking your license is out of the question.

:yeah::yeah:

we are told to document what doctors we notify or what reported labs we give a person, or even who we give report to and from. they are not the exception to rule. it just mean they darn well better follow it up and chart it. like the rest of us on the totem pole.

If it is in writing, get a copy of it, stick it in an envelope that seals up well, and mail it to yourself. When it comes, don't open it- stick it in a safe. Continue to chart when you contact XYZ about an order, etc. If they try to fire you, contact the BON. The envelope (with a date stamp) will prove that you did not make something up after you were fired if the date is before the date of termination. Protect your license!!

You should chart as they say "nothing written, nothing done".