Legal implications of free-text charting

Published

I have started a new job in a new hospital and of course there are differences in policies, but one that I'm particularly concerned about is free-text charting. In my previous job, we were instructed to keep free-text charting to a minimum as what you write can be taken the wrong way (in court). We generally would write notes, but they would be very vague and they were really intended to just chart that you did indeed do a rounding with the patient.

In my new job, the nurses do a free-text note that is intended to give the oncoming shift a rundown of what has been going on with the patient in general, and specifically during your shift. I agree that communication is extremely important, but I feel uncomfortable ENTERING this communication into the patient's permanent chart. It seems to me that free texting about medications I gave, descriptions of wounds etc. is double charting since I've already carefully documented my assessment in the chart. Also, there doesn't seem to be a standard for this, everyone does it very differently and it's not even mandatory. A few nurses say they refuse to enter these notes because of the legal implications.

Any thoughts on this? I'm a little confused and not sure what to think.

Thanks!

Up Vote Up Vote ×
Specializes in Med/Surg, DSU, Ortho, Onc, Psych.

What do u mean by free text charting? I haven't heard this term.

Is it like a running sheet that night staff use sometimes, ie: when everyone has done their main notes, if anything changes it is put on a running sheet.

Is that what ur getting at?

Up Vote Up Vote ×

No, this is asking for trouble and goes against their reasoning for free-charting. Have never come across this, but it sounds like the shift to shift report. Not for the chart. You chart your regular nursing charting in the chart. The 'free for all' that you give to the oncoming nurse stays between you and the oncoming nurse. We objected when they told us we had to have the CNAs present for shift report because then we had to censor what we said for the CNAs ears. I just don't see this as being appropriate unless it is done thoroughly and "chart" appropriate.

Up Vote Up Vote ×
Specializes in Psychiatry, ICU, ER.

I believe free-text charting definitely has a place, and do it all the time in ICU/ER for CYA purposes.

I would not write notes under the circumstances you describe. Report to so-and-so, all information communicated to oncoming nurse, questions answered. Done.

Up Vote Up Vote ×

It's literally opening up a word document and typing away. It's not necessarily a SOAP note or SBAR etc., it's just whatever you want to say. Like I said, communication is vital, but it makes me uncomfortable that my communication to the next shift is on paper and ends up in the patient's permanent chart. In addition to this, we do a hand-written note that is given to the next shift that essentially would be the same information. (And of course, we do a complete head-to-toe assessment on a flowsheet in the chart).

Up Vote Up Vote ×
Specializes in Med/Surg, Academics.

She means you are writing in your own words rather than charting with drop-down or checkbox selections. Other people call it narrative charting.

You don't need to be a lawyer to chart narratively; you just need to learn to write objectively.

Doctors, social workers, and many other healthcare roles do it all the time. Why are acute care bedside nurses so afraid of it? (I think it's because they aren't sure how to do it.)

Drop-down and checkbox charting is so limited that it doesn't always give a clear picture of the patient. After all, your assessment and intervention charting is being driven by the creators of the software or the form. If they didn't make a checkbox or dropdown that matches your assessment or intervention, what do you do then?

Up Vote Up Vote ×
Specializes in Med/Surg, Academics.
It's literally opening up a word document and typing away. It's not necessarily a SOAP note or SBAR etc., it's just whatever you want to say. Like I said, communication is vital, but it makes me uncomfortable that my communication to the next shift is on paper and ends up in the patient's permanent chart. In addition to this, we do a hand-written note that is given to the next shift that essentially would be the same information. (And of course, we do a complete head-to-toe assessment on a flowsheet in the chart).

To avoid those legal liabilities, it shouldn't really be "whatever you want to say." That's where people can get into trouble it they aren't careful. You can always make yours in SOAP, SBAR, ADPIE, or whatever format you choose to keep yourself on track with an objective charting entry.

Up Vote Up Vote ×
Specializes in Med/Surg, Academics.
No, this is asking for trouble and goes against their reasoning for free-charting. Have never come across this, but it sounds like the shift to shift report. Not for the chart. You chart your regular nursing charting in the chart. The 'free for all' that you give to the oncoming nurse stays between you and the oncoming nurse. We objected when they told us we had to have the CNAs present for shift report because then we had to censor what we said for the CNAs ears. I just don't see this as being appropriate unless it is done thoroughly and "chart" appropriate.

Curious. What was being said that a CNA couldn't hear?

Up Vote Up Vote ×
Specializes in Med/Surg, Academics.

Sorry about all my replies. I now know what the OP is saying. :o

You're talking about a shift-to-shift report being part of the permanent chart?

If management insists, maybe you can all come up with a standard format that gets completed, and then any other less-than-savory information passed (he's needy...and I set limits on him by blah, blah, blah) can be verbal?

Up Vote Up Vote ×
Specializes in Critical Care.

Free-text charting is not by itself more legally dangerous than drop-down charting. You can get yourself into trouble if you don't follow some basic rules when free-texting, but drop-down charting can also leave you in legal trouble if it results in charting that is too vague or less-than-accurate.

Where I work, we chart our systems assessments using drop-down options, but then augment that with a written note that is much more patient specific and does a much better job of communicated the patient's assessment, plan, progress, etc, which is the goal of charting, use in court is secondary. This note is essentially a shift-to-shift report than can be accessed by other caregivers and at other times.

The only advantage to drop-down charting, and why it's used so often, is that it facilitates data mining, which can't be done with free-texting.

What EMR are you using?

Up Vote Up Vote ×
Specializes in HH, Peds, Rehab, Clinical.
I have started a new job in a new hospital and of course there are differences in policies, but one that I'm particularly concerned about is free-text charting. In my previous job, we were instructed to keep free-text charting to a minimum as what you write can be taken the wrong way (in court). We generally would write notes, but they would be very vague and they were really intended to just chart that you did indeed do a rounding with the patient.

In my new job, the nurses do a free-text note that is intended to give the oncoming shift a rundown of what has been going on with the patient in general, and specifically during your shift. I agree that communication is extremely important, but I feel uncomfortable ENTERING this communication into the patient's permanent chart. It seems to me that free texting about medications I gave, descriptions of wounds etc. is double charting since I've already carefully documented my assessment in the chart. Also, there doesn't seem to be a standard for this, everyone does it very differently and it's not even mandatory. A few nurses say they refuse to enter these notes because of the legal implications.

Any thoughts on this? I'm a little confused and not sure what to think.

Thanks!

I may be the odd one here, but I PREFER narrative-style charting (I think we are talking about the same thing!). YEARS ago when I first started doing EMS, ALL of our charting was done by hand and I was taught to write it all out, step by step what we did for our patients (if you didn't write it, it didn't happen!). I learned to be VERY thorough and by golly my charts told the entire story. It was very hard to switch over to pre-made templates and to check a box to sum up a patient. I still tended to write it all out pretty much again in the summary box. I will tell you this: of the 3 times I was subpeonaed for court regarding one of my calls, I was always very happy that I tended to be overly-wordy with my charting!

Up Vote Up Vote ×
Specializes in HH, Peds, Rehab, Clinical.
She means you are writing in your own words rather than charting with drop-down or checkbox selections. Other people call it narrative charting.

You don't need to be a lawyer to chart narratively; you just need to learn to write objectively.

Doctors, social workers, and many other healthcare roles do it all the time. Why are acute care bedside nurses so afraid of it? (I think it's because they aren't sure how to do it.)

Drop-down and checkbox charting is so limited that it doesn't always give a clear picture of the patient. After all, your assessment and intervention charting is being driven by the creators of the software or the form. If they didn't make a checkbox or dropdown that matches your assessment or intervention, what do you do then?

LOL, I should have kept reading and then just said "yeah, what she said"! LOL

Up Vote Up Vote ×
+ Join the Discussion