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How to chart to protect license

Posted

Specializes in ICU.

I work at a smaller community hospital that is rich in acuity, but lacking in resources. That being said we have a very high turnover, and the nurse:patient ratio is usually suffering because of lack of staff. This in turns leads to us being very busy, and I find I am staying 30 minutes late nearly every shift to "cover myself" and make sure I have charted thoroughly. I work FT in ICU, and pick up casually in ER. We have some good providers, and many others that are less inspiring, to say the least. I worry heavily about finding myself in a lawsuit (not due to my actions, but as someone who has been part of the patient's care) for an assortment of reasons. I am not saying that patients are being intentionally mistreated or anything like that, but it seems we have some long delays in care sometimes due to certain systemic issues, and we don't have the proper systems in place to rectify this. The high turnover has led to the remaining staff being allowed to essentially do as much or little as they want, so long as they do what is audited (restraints, titration, etc). 

I have a commitment to this community and these patients, and would like to work here longer as I am getting great experience, and can see daily how my interventions and advocacy affect patient care positively.

All of this being said, how do I document to cover myself? What are things nurses are being pulled into court about? What are obvious things nurses should be documenting that they may not be? I try to be as specific and detailed as possible (ex: 0900-informed of troponin of 10. 0901- author informed Dr. ______ of troponin 10.) but still am fearful, and want to minimize my risk of ever being pulled into court and not having documented properly/thoroughly.

 

I am looking for nurses with experience with any of the above, legal experts in the nursing field, or anyone else who would be so kind to point me in the right direction.

igtgrnokbye

Specializes in looking busy. Has 2 years experience.

There is a legal nurse on these forums that you can ask your questions to. 
 

Legal teams generally have their own medical chart reviewers keep that in mind. Another good resource is to meet with your hospital attorney, they should have an office in the hospital building. Ask them their experiences and advice. Take a charting class and have your hospital pay for it. 
 

Lastly your chart should reflect realistic efforts to address the patients condition based on guidelines. It doesn’t have to be cutting edge treatment, but it should be realistic. 
 

Check your BON website also for malpractice advice on investigations. Carry malpractice insurance
 

Honesty goes a long ways. If you see gross systemic issues bring it up to your practice counsel. If you don’t have a practice counsel request to form one. 
 

30 mins post shift is well worth it to chart properly. 

Jory, MSN, APRN, CNM

Has 10 years experience.

On 11/27/2020 at 12:12 AM, RN_atlast said:

I work at a smaller community hospital that is rich in acuity, but lacking in resources. That being said we have a very high turnover, and the nurse:patient ratio is usually suffering because of lack of staff. This in turns leads to us being very busy, and I find I am staying 30 minutes late nearly every shift to "cover myself" and make sure I have charted thoroughly. I work FT in ICU, and pick up casually in ER. We have some good providers, and many others that are less inspiring, to say the least. I worry heavily about finding myself in a lawsuit (not due to my actions, but as someone who has been part of the patient's care) for an assortment of reasons. I am not saying that patients are being intentionally mistreated or anything like that, but it seems we have some long delays in care sometimes due to certain systemic issues, and we don't have the proper systems in place to rectify this. The high turnover has led to the remaining staff being allowed to essentially do as much or little as they want, so long as they do what is audited (restraints, titration, etc). 

I have a commitment to this community and these patients, and would like to work here longer as I am getting great experience, and can see daily how my interventions and advocacy affect patient care positively.

All of this being said, how do I document to cover myself? What are things nurses are being pulled into court about? What are obvious things nurses should be documenting that they may not be? I try to be as specific and detailed as possible (ex: 0900-informed of troponin of 10. 0901- author informed Dr. ______ of troponin 10.) but still am fearful, and want to minimize my risk of ever being pulled into court and not having documented properly/thoroughly.

 

I am looking for nurses with experience with any of the above, legal experts in the nursing field, or anyone else who would be so kind to point me in the right direction.

You don't need a legal expert, all you need is to go to your BON website and see what reasons the BON are sanctioning licenses.  In the example you gave, you don't need to go into that much detail b/c if you have a critical lab just check to make sure the lab documented they called you, if they did, that is part of the patient's chart and you don't need to chart it again.  But you do need to chart (you don't need a time if it is a couple of minutes of when the event occurred as the charting will capture the time) that you contacted Dr. Smith and you need to chart any follow-up.  

When I worked the floor, I had managers and co-workers that didn't like my charting b/c they said I wrote too much. That is the one thing hospitals don't have control over--your charting.  You chart what you feel like you need to chart, but you don't have to double chart.  If it is documented elsewhere you don't need to chart it again.  I once had a stupid manager that wanted us to triple chart a few things and I absolutely refused.  

You should never fear being pulled into court if you have documented what you are supposed to. I have been called into court more than once (nothing I personally did, just giving my personal account for things) and it never bothered me.  The nurse that needs to be fearful is the one that charted hardly anything at all.  

If you didn't chart it, it didn't happen.  Period.  

Edited by Jory

hppygr8ful, ASN, RN, EMT-I

Specializes in Psych, Addictions, SOL (Student of Life). Has 19 years experience.

18 hours ago, igtgrnokbye said:

There is a legal nurse on these forums that you can ask your questions to. 
 

Legal teams generally have their own medical chart reviewers keep that in mind. Another good resource is to meet with your hospital attorney, they should have an office in the hospital building. Ask them their experiences and advice. Take a charting class and have your hospital pay for it. 
 

Lastly your chart should reflect realistic efforts to address the patients condition based on guidelines. It doesn’t have to be cutting edge treatment, but it should be realistic. 
 

Check your BON website also for malpractice advice on investigations. Carry malpractice insurance
 

Honesty goes a long ways. If you see gross systemic issues bring it up to your practice counsel. If you don’t have a practice counsel request to form one. 
 

30 mins post shift is well worth it to chart properly. 

If your hospital doesn't pay for it - take the class anyway. You will get CEUs which you need and you can write the cost of the class off your taxes. I took such a class years ago and it has been invaluable to me. 

The facilities we work don't always pay for education and CEUs. A few years back I took a 5 day seminar in understanding the issues of LGBTQ youth. It cost me about 1500.00 because I had to fly to the state where it was and stay in a hotel. But I got my 30 CEUs for that period and wrote the whole thing off a a work expense.

Hppy