CYA charting tips & tricks

Our computer charting has choices to click on, but I always annotate if my patient doesn't fit that. There is a section you can chose that will allow for narrative notes for each thing you chart on. It's great. That way, I am not confined to just the choices given.

For instance, we have to chart on a patient's GCS. Well, obviously, if you have a patient who is intubated, they will not be verbally communicating. So I always chose the "0" which states that patient does not verbalize, but I annotate that the patient is intubated, and if they are trying to mouth words or point at things, etc. I always annotate that they are making attempts at nonverbal communication.

Another example is if I have a patient who can't tell me they are having pain while doing a Homan's, I annotate that that there is no redness or swelling noted bilaterally. I have two preceptors....one who has been nursing for almost 25 years and one who has been an RN for 5 years. It's very interesting to see how they evaluate my charting and how they chart themselves. The one who's been a nurse for so long tells me to make sure I don't get too wordy and say too many unnecessary things because it can screw me if I ever get pulled into court. The one who has not been a nurse as long tells me to be VERY specific and write as much as I feel I need to because if I get pulled into court, I have my documentation to back me up....LOL. I go somewhere in the middle. I've been told by my preceptors and my supervisors that my charting is top-notch (which knocked me over because I never feel completely confident).

It's really hard to say what will save your butt in court or not...sigh. It's a shame that we have to think like that. That is one reason I've contemplated Correctional Nursing. The inmates can grieve you all they want, but the grievances must be validated by the Nursing Supervisor and a board who decides if it's worth going to court over. They rarely make it past those people. The nursing supervisor has been there over 20 years and she's been grieved once by an inmate that resulted in her having to pay a restitution of.....$5.....LOL. It was because she didn't give him his diabetic meal that evening for one reason or another. I don't like having to worry about losing my license and it's a real shame that this society has come to that.

Melanie

Hi Melanie,

Thank you for the very thorough post. It really is shame that we have to be "ofensive" in our charting in healthcare today. (I sometimes hate the fact that while I'm charting, I have to think about that cute little old lady sitting in a court of law with a jury to decide my fate).

I've heard the same thing in regards to charting too much which I definately have a tendency to do because #1 I'm fresh out of nursing school and #2 I was also praised for my documentation as well. I was also a bit shocked at times when my instructors would use my work as an example and am now wondering what they were talking about since I'm having a hard time trying to find that "middle" ground between charting too much and too little. I hope that I'll find "my way" of charting and in the mean time, I hope that I don't do anything that will put me in the courts trying to defend myself with words I charted years from now. *crossing my fingers*

Thanks again for your post and for your advice regarding the nonverbal patients - which I always seem to have a to find creative ways to compensate the computer charting for. :)