CYA: Charting

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Specializes in Ante-Intra-Postpartum, Post Gyne.

Does anyone know of a good book on proper charting? What to chart, how much, when. How late can you do a late entry chart note? Ect. Some patients you have to CYA and you feel like you really need to chart extra well. Some nurses tell me to document everything in detail and others say that you can hang yourself on too much charting. Any books or even suggestions from experienced nurses; particularly in OB, is great appreciated.

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I don't have a book to offer but I can say that I have ALWAYS charted to CYA.

That sweet old man and his family treat you well now but if he falls out of bed on your shift and has a brain bleed from hitting his head you'd better chart all the times you tried to get assistance from the MD and were waiting for a sitter to be at his bedside or the family left the room, etc., etc.

I always wanted to be able to paint a clear picture for myself if I ever HAD to defend my actions and nursing judgment in the future.

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Specializes in Corrections.

Buy the book "Chart Smart"

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Specializes in LTC, Memory loss, PDN.

Alternatively, attend a seminar, by a nurse lawyer, on charting. It's an eye opener and money and time well spent.

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I don't have a book to offer but I can say that I have ALWAYS charted to CYA.

That sweet old man and his family treat you well now but if he falls out of bed on your shift and has a brain bleed from hitting his head you'd better chart all the times you tried to get assistance from the MD and were waiting for a sitter to be at his bedside or the family left the room, etc., etc.

I always wanted to be able to paint a clear picture for myself if I ever HAD to defend my actions and nursing judgment in the future.

Just wanted to say I had ONE incident in 18 years. A patient wished to go AMA, was angry, etc, etc. Tried everything to let them know the ramifications of their decision-contacted MD, Nursing supervisor, etc. Charted point by point EVERY expletive and how I responded (right after it happened so there would be a timeline). This was in a critical care unit and there were many nursing and nursing supervisor witnesses.

A few weeks later got a call from my manager that there was a complaint against me-unfit care, didn't give this person information about how their decision would impact them ,etc.,etc.-----actually, their insurance company wouldn't pay for the stay since they went AMA-said we didn't tell them. The kicker was-I DID state to this person and their family that the insurance company may not pay if you go AMA AND I charted it and I had witnesses:)

My charting supported everything and I never heard another word.........

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