Documentation is your friend.


Boy, that statement has never been more true than this week.

I have been called on the carpet I don't know how many times since I started work at my soon-to-be-former job about my documentation. No, not because of the lack of it, but because Doc felt I 'wrote too much' and 'wasted paper'. Well, I ignored the edict and kept right on documenting everything, from anecdotes about what the patients were going through, to notes about a potential problem with prescription abuse, to noncompliance.

And three times this week alone, it's saved our butt.

I was sent home sick the other day, running a fever, and I came back in to see a chart on my desk, waiting for me to enter it into our database of deceased or dismissed patients. The patient had died, and he was not that old. No one knew what happened, but there had been mention of a lawsuit based on poor medical care. My OM and the office staff had reviewed the chart, and noticed that, every time he was seen, his B/P was to the moon, and always, always, he had not been taking his meds, not taking them correctly, or engaging in other behavior that could compromise their effect. Almost every time, I adjusted the meds, and every time I did, I wrote for him to return in a week for a recheck. He never did. Referral to cardio? He never went. All documented.

Another man is currently involved in a suit regarding a surgery. The last time he took it upon himself to just show up without an appointment ( not uncommon at my clinic), he brought along an 'advocate', and proceeded to request bloods be drawn for some very odd tests, that required special tubes and processing. We did not have the necessary supplies, and he was told that we would at his next scheduled appointment. He then said that he did not want the bloods to go through our dedicated lab, due to an issue with the surgery and the suit. Well, that issue wasn't debatable, and he was told that.

On his appointment date, he refused the bloods, and said that they had already been done. I documented as much, and when he called today to request an Rx for those tests, we had him dead to rights. No room to try and say that we just didn't do them, as he asserted.

And lastly, the patient who consumed 1 and 1/2 month's worth of meds in 3 weeks or less, tested negative for her prescribed meds, and positive for meds not prescribed by us. She asserted that she 'had told us and told us' that the meds weren't working, and so she self-adjusted, took more than double her prescribed dose, and then bought more meds off the street. She was told we could not see her anymore.

Thanks to my 'anal' chart notes, we could prove that the abuse of meds had been ongoing, by the patient's own admission, and that she had been counseled. We had documentation that she complained of no increase in pain, and that she had refused treatment and referrals for her 'nerves'. In short, nothing was good enough, unless it was an excuse to complain.

I remember being taught in school about charting, and I never really gave it a lot of thought at that time. Now, however, I'm glad I learned that. I am SO glad that I stuck to my guns and kept charting everything. Just wondering, has charting ever saved your rump?


Specializes in PICU, ICU, Hospice, Mgmt, DON. Has 18 years experience.

Just the old adage....

If you didn't write wasn't done....!!!


176 Posts

In this case, more is more! Sure glad you CYA with documentation.


6 Posts

Specializes in ER, MS, OB-GYNE, Critical Care. Has 3 years experience.

I was also saved once because of my charting. I am an ER nurse and a terminally ill patient came in our department requesting to be admitted. We catered to her immediate needs. the Resident on Duty finished managing the said patient and needed to contact her attending physician to give an update regarding her status. Unfortunately, the attending physician's mobile, landline and clinic phone were all not responding. We even tried calling her mobile for 8x but were being cut off. the ROD assumed that maybe the AP was busy or were driving. Feeling the urge to document these, i wrote down on my notes all our efforts of informing her (AP). When I endorsed the patient to the nurse on duty incharge for the patient, I informed him of our efforts of informing the attending physician. Fast forward, the patient went into cardiac arrest and died after all efforts were made. while the code blue team, including me, were doing post mortem care, the resident on duty updated the attending physician regarding the management of the patient and what were done. The attending physician went furious over the phone because she WAS NOT informed that she had an admission that day. She denied receiving calls and SMS. She immediately went to our Nursing Supervisors and Medical Director insisting that this was our laps and that the patient could've been alive if she knew of the admission.

I presented my notes and the exact time where we made the calls, including the records in the operator of our calls made. Even the sent items of the SMS were saved. The management sided with my evidence and the attending physician was given a reprimand by the hospital for denying facts and not attending to newly admitted patients.


27 Posts

Good job! I'm a nursing student externing at a hospital. I am responsible for charting everything I do. My main two preceptors know that I am pretty thorough, when I work with other nurses they laugh at my charting. But this goes to show that sooner or later a scenario will arise where charting is going to save my butt.

Good habits start young and continue the more you do them!

AngelfireRN, MSN, RN, APRN

2 Articles; 1,291 Posts

Specializes in med-surg, psych, ER, school nurse-CRNP. Has 15 years experience.

Geez, what a card. I hope the reprimand had the desired effect. That's just lousy.


6 Posts

Specializes in ER, MS, OB-GYNE, Critical Care. Has 3 years experience.

yeah. That same doctor is notorious for denying orders made and telephone orders. When she is giving telephone orders, I see to it that I have a tape recorder beside me and that I document the Date, Time and the flow of our conversation. One unlucky dude was kicked out of our hospital because he administered a medicine which she ordered but soon denied after the patient exhibited adverse reactions. poor guy, he doesn't have any evidence to support him that time. that's why charting is OUR protection from these types of doctors.

Specializes in Med/Surg, DSU, Ortho, Onc, Psych.

Let this post be a lesson to all you newbie nurses out there, document like mad to save your bee-hind! (in the ED where I work every now & then, we document everything on the patient's running sheet, & I mean everything - whether they have a s/wich & coffee, refused commode, were swearing, abusive, etc). It's a great idea.


587 Posts

Nope, never had a dramatic save lkie you guys have. I too, "overchart." and trust my gut when I have a "lawsuit special of the day." assigned to me.


38,333 Posts

New nursing supervisor (home health) on a supervisory visit noted no entries on the TAR at all except by one nurse (there are two shifts per day), and mostly holes on the MAR, and made the remark to me that it looks like the nurses need to be involved in a lawsuit to find out that they need to do their documentation. Since I do my documentation like I am supposed to, I often wonder what position I would be in should the record go into a courtroom. Even though my charting is there, I still see me being painted with the same brush and getting triple the third degree because of what others refuse to do.


1 Article; 3,037 Posts

Specializes in Medical.

I work with nurses who chart by exception and wonder how they'd ever do if something happened down the track. I was reminded of this several years ago, when a patient complaint had me called into my then-manager's office - the patient'd had a renal transplant and made three allegations: that I hadn't done her CVC dressing, and hadn't given her pain relief before dressing the surgical wound.

Fortunately I'd documented in my notes about why I didn't do the CVC dressing (clean, dry, dressed in dialysis during bridging haemo, significantly immunosuppressed), and noted that the prescribed analgesia appeared to have limited effectiveness despite being administered half an hour prior to the dressing change, and that I contacted the resident to review (followed by a medical entry explaining why they increased the dose).

My NUM wasn't close to being my biggest fan, but that was the end of the complaint.


827 Posts

Specializes in pediatrics, public health.

The parents of one of my patients sued the hospital I worked at and, among other things, claimed they hadn't been taught certain things they needed to know in order to take care of their medically fragile child at home. My NM told me she was very glad when she saw that I was the one that had done the teaching, because she knew that all of the teaching I had done with them would be well documented -- and it was, showing that we had in fact taught them all of the things they claimed we hadn't taught them.

Kind of ironic, since my NM had also complained to me at times that my notes were too long!