CYA: Charting

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.

Buy the book "Chart Smart"

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

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.........