Defensive Charting

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Does anyone know where there may be a class (online or otherwise) to take to find out how to chart and avoid lawsuits? I'm a relativetly new nurse and only 2 months on the med/surg floor and I'm trying to figure out what the right/wrong things to say are. i notice some rn's write very detailed notes. others, barely any.

suggestions?

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Specializes in Hospital Education Coordinator.

the more you say the more you have to defend.

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Specializes in CTICU.

... yet if it isn't written, it didn't happen.

I did go to a class taken by a malpractice lawyer showing how things got twisted in court cases! Maybe check with your BON.

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Specializes in Med/surg/tele/OR.

It is tricky at first to figure out what to chart. Dont' write stories simply state the facts. Chart any procedures you do and patient response, chart pain and pain meds. The main thing is to stick to the facts only the facts, don't offer your own thoughts on things or try to write a story.

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Specializes in Infusion Nursing, Home Health Infusion.

I took a GREAT course on nursing documentation by Western CEUs.the best one I have ever seen...they instruct on how to chart so that you can protect yourself. They also have multiple real life examples and lawsuit examples...it was fascinating. I have always been interested in documentation so I bought the course.....there courses are ALWAYS wonderful .I always have them send me the book so I can have it for future reference as opposed to the on-line version

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