Charting and blanks

[Jabramac]

Hello,

I have a question. In my ER we use a computer system for charting with a template in a word processor like program that has prechosen fields to fill in like vitals, hx, allergies, meds, domestic violence, immunizations, tetorifice status, and smoking hx. Per our hospital policy adult pts who present with things that do not require knowledge of immunizations or tetorifice do not need these two areas addressed. So, I leave those fields blank. However, I have been told by other nurses that it is not acceptable to even leave the field in the form if it is not addressed and is left blank, and the whole section needs to be taken out and deleted (which we are able to delete the whole field in our form). She argues that for legalities it appears I did not do anything, and I can not leave sections blank on a chart. My argument is that on a paper versions of flow charts (not our computer system) there are often fields that are left blank, and legally speaking if it wasn't addressed it would not matter if it was left blank or taken out, it wasn't addressed. What do you all think? Am I wrong and I need to either make a notation on each field (even though it is not required per hospital policy) or delete the entire field so the question isn't on the chart?

Thanks,

James

[UK2USA]

I can see your point, but I think that leaving blanks in any form is a little dangerous. Let me explain: about 3 years ago I was working an agency shift at a hospital where a nurse had made an error (she left the allergy list blank and the patient was given penicillin - which she was allergic to). The nurse was really relieved that her admission paperwork had blank areas on it so that she could go back 2 days and complete them to avoid getting into trouble. She was caught, fired and went before the BON. The moral of the story is that if you can delete a category to avoid an empty space - do it. If you can chart n/a for not applicable areas - do it. But never, ever leave a chart blank. Think about how you would feel infront of a lawyer with a chart that you half completed - with the other half filled in incorrectly by someone else..... and your signature at the bottom.

Hope this helps

[rn/writer, RN]

hello,

i have a question. in my er we use a computer system for charting with a template in a word processor like program that has prechosen fields to fill in like vitals, hx, allergies, meds, domestic violence, immunizations, tetorifice status, and smoking hx. per our hospital policy adult pts who present with things that do not require knowledge of immunizations or tetorifice do not need these two areas addressed. so, i leave those fields blank. however, i have been told by other nurses that it is not acceptable to even leave the field in the form if it is not addressed and is left blank, and the whole section needs to be taken out and deleted (which we are able to delete the whole field in our form). she argues that for legalities it appears i did not do anything, and i can not leave sections blank on a chart. my argument is that on a paper versions of flow charts (not our computer system) there are often fields that are left blank, and legally speaking if it wasn't addressed it would not matter if it was left blank or taken out, it wasn't addressed. what do you all think? am i wrong and i need to either make a notation on each field (even though it is not required per hospital policy) or delete the entire field so the question isn't on the chart?

thanks,

james

the problem with your argument is that "it wasn't addressed" could look like an error of omission. why wasn't it addressed? did you forget?

if you have the option of deleting the section and you don't do it, how can anyone else know that you didn't just miss something? i'd fill in n/a or delete what doesn't apply. either one shows you made an evaluation whereas leaving an item blank does not.

[Jabramac]

hank you for your input. I see your point. The only thing is that because it is an electronic chart the way the program works uis that no one else can go in and change things on the sections I entered, so no one else can fill in my blanks. If I went back after the fact and changed the entries the electronic chart would reflect that in time stamps on the entries. That is were I have thought "what would happen if I was in front of a lawyer?" I feel confident I could say "those sections were left blank, because as you can clearly see the chart reflects those sections were not needed."

[rn/writer, RN]

hank you for your input. I see your point. The only thing is that because it is an electronic chart the way the program works uis that no one else can go in and change things on the sections I entered, so no one else can fill in my blanks. If I went back after the fact and changed the entries the electronic chart would reflect that in time stamps on the entries. That is were I have thought "what would happen if I was in front of a lawyer?" I feel confident I could say "those sections were left blank, because as you can clearly see the chart reflects those sections were not needed."

I'm pretty sure you were replying to the post before mine, but I'll reiterate my point anyway. Leaving blanks when you have the options of putting N/A or deleting an unnecessary section could suggest that you, a) got distracted and skipped over it, or, b) were too lazy to remove it. Why set yourself up for problems?

[Aneroo, LPN]

We use the computer charting too. One of our pop-up's is "N/a to patient complaint" or "Patient denies complaint".

I do delete some stuff (such as prior to transport and condition on scene info if they came in by themselves). I agree, delete or address.

[mshooha]

We are not to computerized charting yet, but a good rule of thumb is never leave anything blank, N/A or get the info. I agree with everyone else, don't set yourself up!!

[KatieBell]

Chances are- if a lawyer is asking why something was left blank, at this point the blank is no longer "not applicable."

Better to put no complains, or no abnormal findings....

for the templates that drop down, I usually try to fill out as completely as possible. Yes, none of us feel like we have a lot of time in the ED, but i sure do not have time for a lawsuit.