Nurses Notes: Guidelines On What Not To Chart

[TheCommuter]

The medical record is a permanent collection of legal documents that should supply an all-encompassing, accurate report concerning a patient's health condition. Physicians, nurses, social workers, dieticians, mid-level providers and other members of the interdisciplinary team contribute to each patient's medical record to paint a comprehensive picture of the patient's status along with any care that has been rendered. The patient's chart needs to contain enough pertinent data to enable each member of the healthcare team to render care in an integrated manner.

Most nurses have probably heard the old adage, "If it was not charted, it was not done!" However, some types of documentation should not be entered onto the patient's medical record for various reasons. Since the chart is a permanent record that is subject to entrance in court-ordered legal actions, nurses and other healthcare professionals must exercise extreme caution when documenting. The following is a very general list of the notations that nurses should not document in the chart.

Never document nursing care before it is provided

Nursing staff should never chart assessments, medication administration or treatments prior to actually completing the tasks because this may contribute to an inaccurate record filled with incorrect data. If the medical record contains nursing care that was never performed, this is fraudulent in some cases. Always remember that other clinicians may depend on correct documentation to assist in formulating decisions regarding patient care.

Do not routinely document care rendered by others

It is allowable in several instances to document care, tasks or procedures performed by another individual. However, the documentation in the medical record must clearly indicate the individual who actually rendered the care. If the house nursing supervisor applied the four point restraints, be sure to identify him/her as the person who carried out the task. But do not regularly chart actions that have been performed by other people. If a coworker or super-ordinate does something incorrectly that results in patient injury or death, you do not want culpability.

Never leave blank spaces between entries

In this day and age of prevalent electronic medical records, some facilities and healthcare settings still utilize paper charting. Nurses who still use paper and pen to chart must never leave blank spaces between entries. These unused spaces might be used by others to add questionable notations, so always be sure to draw a line across blank areas.

Do not chart that a patient is in pain unless you have intervened

No prudent nurse would even think of documenting "Patient complains of radiating chest pain," without subsequently documenting what was done about the issue. Thoroughly chart all notifications, interventions and actions taken to avoid liability.

Do not record another patient's name in the medical record

Let's assume that Mr. Wright gets into a physical altercation with his roommate, Mr. Robinson. The nurse is violating Mr. Robinson's confidentiality if she documents his name anywhere in Mr. Wright's medical record, and vise versa. To get around this issue, employ a vague description such as 'the roommate' or the 'patient in bed A.'

Whenever possible, do not document subjective descriptions

Attempt to refrain from charting subjective descriptions such as "Patient's blood pressure is really high." Obtain accurate vital sign checks, intakes and outputs, and other objectively measurable data and record this information in a timely manner.

Do not openly criticize the care that was rendered by a coworker

The medical record is a group of documents that should provide a comprehensive view of the patient's condition. Conversely, the medical record is not appropriate for criticizing care performed by other members of the healthcare team. Berating a fellow nurse, nursing assistant or technician in the nurses notes will accomplish nothing other than perhaps fuel the fire of state surveyors, malpractice attorneys and anyone who happens to read the chart at a later date.

Do not mention short-staffing in the medical record

Documenting the existence of staffing issues in the medical record rarely, if ever, helps to increase the number of staff members. On the other hand, medical malpractice lawyers love reading nurses' notes that provide details about a facility's lack of staff.

Do not make insulting references to patients while charting

Try to avoid referring to patients as 'drug seekers,' 'rude,' 'vulgar,' 'profane,' or 'crazy' when documenting. Utilize objective phrases and direct quotes whenever possible such as 'Patient states to this writer, "You are a ___ (B-Word) and I will kill you!"'

Do not ever document the existence of incident reports

Never document the preparation of an incident report in the nurses notes. The incident report is an internal document meant to facilitate improvement of systems and processes within the healthcare facility. If a nurse charts a note describing that an incident report was completed, this internal form now becomes subject to discovery by external medical malpractice lawyers if legal action were to arise at a future time.

More Tips For Charting...

 

[SoldierNurse22, BSN, RN]

redhead_NURSE98! said:

It'd be great if the patients said these things to every nurse caring for them, and I do not know of that, and interestingly, this particular nurse is the only person in whom EVERY one of her patients confides. She's trying to make herself look better and make everyone else look like they're falsifying documentation.

That's a matter of personal motivation, and I agree--that's not right. The point is one shouldn't avoid charting something that is potentially inflammatory just because they're trying to protect someone else.

[jewel53]

One thing that raises a potential red flag for me as a legal nurse consultant is documentation that may be viewed as "defensive" documentation that appears to place blame on the patient. For example, a patient in a long-term care facility frequently refuses to take their medications or to allow wound dressing changes to be performed. Simply charting said refusals took place is insufficient, making the charting appear to shift the blame to the patient for complications that may have resulted from said refusals. Be sure to document interventions attempted to try and achieve the patient's compliance. Were vital signs taken to evaluate if the patient may have been ill? Did the patient need pain medication before the prescribed times for dressing changes? Did the nurse return to the bedside at another time, say 10 minutes later, and present the meds to the patient? Was the care plan changed to indicate the patient's medication refusals? Psych eval for possible depression? In essence, why was the patient refusing to comply? Nurses can no longer say the patient chose not to comply without documenting attempts made to gain compliance from the patient. Is there documentation that the physician was notified? Were changes made in the patient's care plan, and were those changes in the care plan initiated? In short, document sufficiently to cover your actions should an adverse situation or litigation present itself months or years down the road. You will find those interventions you may have attempted departed from your memory.

[Loo17]

\ said:

One thing that raises a potential red flag for me as a legal nurse consultant is documentation that may be viewed as "defensive" documentation that appears to place blame on the patient. For example, a patient in a long-term care facility frequently refuses to take their medications or to allow wound dressing changes to be performed. Simply charting said refusals took place is insufficient, making the charting appear to shift the blame to the patient for complications that may have resulted from said refusals. Be sure to document interventions attempted to try and achieve the patient's compliance. Were vital signs taken to evaluate if the patient may have been ill? Did the patient need pain medication before the prescribed times for dressing changes? Did the nurse return to the bedside at another time, say 10 minutes later, and present the meds to the patient? Was the care plan changed to indicate the patient's medication refusals? Psych eval for possible depression? In essence, why was the patient refusing to comply? Nurses can no longer say the patient chose not to comply without documenting attempts made to gain compliance from the patient. Is there documentation that the physician was notified? Were changes made in the patient's care plan, and were those changes in the care plan initiated? In short, document sufficiently to cover your actions should an adverse situation or litigation present itself months or years down the road. You will find those interventions you may have attempted departed from your memory.

Any time I have charted a refusal, I would include the vital signs, patient orientation, patient's stated reason for the rejection in quotations, the education I provided for the reason for medication/wound care/treatment, and the patient's response in quotes. I would then document the MD I notified and the time.

Sometimes patients don't understand why they need to take a particular medication or treatment even if it has been explained before, or they may not understand the consequences of noncompliance. Of course, sometimes patients don't care too. When I worked on the floor, I often had patients that hated thickened liquids and would refuse them. Usually, I would hear it's about their quality of life and wanting to enjoy it. It was beautiful when you could get through to them and help them understand that with this small sacrifice (learning to tolerate thickened liquids), their quality of life could improve because they won't be in the hospital being treated for aspiration pneumonia every other month and will be home maintaining their independence. For the patients that decide they don't want to follow the order, It's essential to chart the initial teaching you did, that you notified the doctor, the patient's response, etc., as stated above, but also to do follow-up charting if you work with the patient again saying that you reinforced the teaching. This will help protect you and help others working with the patient.

[flashpoint]

One thing an attorney told us is to make sure we quote correctly. There is a vast difference between them.

The patient states, "This is the worst pain I have ever had."

The patient states this is the worst pain she has ever had.

The patient states, "This is the worst pain she has ever had."

Only what the patient says goes in quotation marks. If someone is reading the last line correctly, they should probably be asking who the patient is talking about.

[MunoRN, RN]

jewel53 said:

One thing that raises a potential red flag for me as a legal nurse consultant is documentation that may be viewed as "defensive" documentation that appears to place blame on the patient. For example, a patient in a long-term care facility frequently refuses to take their medications or to allow wound dressing changes to be performed. Simply charting said refusals took place is insufficient, making the charting appear to shift the blame to the patient for complications that may have resulted from said refusals. Be sure to document interventions attempted to try and achieve the patient's compliance. Were vital signs taken to evaluate if the patient may have been ill? Did the patient need pain medication before the prescribed times for dressing changes? Did the nurse return to the bedside at another time, say 10 minutes later, and present the meds to the patient? Was the care plan changed to indicate the patient's medication refusals? Psych eval for possible depression? In essence, why was the patient refusing to comply? Nurses can no longer say the patient chose not to comply without documenting attempts made to gain compliance from the patient. Is there documentation that the physician was notified? Were changes made in the patient's care plan, and were those changes in the care plan initiated? In short, document sufficiently to cover your actions should an adverse situation or litigation present itself months or years down the road. You will find those interventions you may have attempted departed from your memory.

Maybe it shows how fickle court rules and health department findings can be, but we've had the opposite experience recently.

In one case, a patient's refusal of treatment wasn't sufficiently accommodated, partly because a Physician falsely assumed that a psych consult that diagnosed depression was a justification for denying the patient's right to refuse.

In another, repeated attempts to "gain compliance" were found to be excessively coercive in civil court and by the health department.

It's certainly possible to fail to ensure the criteria and associated charting for refusing treatment, but in our experience and according to the legal briefs we were provided, it would appear that it's also just as possible (if not more possible) to be too restrictive.

It seems a significant component is the premise that patients must be "compliant" with their care plan, based on a false/old-fashioned definition of a patient's plan of care. The patient's plan of care is, by definition, only those the patient agrees to. If they disagree with part of their care plan, then the care plan is non-compliant, not the patient. This seems to get confused with the medical plan of care, which is what Physicians would do if we pretended the patient had no say in the matter.

The charting is undoubtedly essential, but it's not that significantly different from what's required if the patient doesn't refuse; for instance, a patient who refuses a medication needs to be informed of the purposes, side effects, etc. of the drug, the same components are required if the patient doesn't deny the medicines. One could undoubtedly document insufficiently and fail to intervene sufficiently, but one could just as quickly interfere excessively.

[Starfire61]

Great post, jewel53; thank you for sharing how too-limited charting in today's litigious society just doesn't cut it. When I entered nursing 17 years ago if a pt refused a treatment, their meds, etc., that is all you wrote in your narrative; pt refused their 1700 meds. Between the overpopulation of malpractice attorneys and the increasingly stringent documentation requirements of Medicare, short, concise nursing notes is a thing of the past.

[Starfire61]

Hi Loo17,

The information you include in your documentation upon encountering a pt refusal is fabulous; very thorough. I document pt refusals in the same manner, adding the name and rank of the clinical supervisor in the office that I called and notified of the pt's denial, per protocol of the home health company I work for. That being said, when I am caring for an Alzheimer's or dementia pt who does not have the benefit of a family member to oversee their medical care or a personal care provider to watch over them; I know that I just educated a pt who is not of sound mind, and not capable of understanding the consequences of refusing their meds, or, treatment. The pt's mental status is part of their Dx, so it's not a newsflash when the appropriate people are called that they have refused whatever I am there to do for them. Without a go-to person with a medical POA that I can call to obtain their consent on the patient's behalf, my hands are tied, and I have to leave without providing the patient the care they need. Having good documentation of the pt's refusal, action is taken, etc., is good, but you still have to walk away knowing you could not provide the care the pt needs. Have you ever run into this situation, and if so, were you able to find a way to provide care?

[Aquamarine0203]

I agree with you; I believe that objective phrases made by the patient to the nurse should be documented accurately. But my NM disagreed with me; she said I should have re-worded it. When I told her that documentation, as far as I know, should be factual and concise, guess what? This is one of her grounds for terminating me.

[All4NursingRN]

Nice thread. Some of these seem obvious, but I have come across quite a few nurses who do not know particular simple documentation pearls.

[ambitiousblonde]

Just wondering if any fellow nurses come across documentation from CNAs on vital signs (not WNL) stating/annotated "notified xxx, RN," and they never actually informed you. How do you handle this? It seems as though my NM feels (has previously stated) I have a "strong personality" and "come across as being too harsh." I think the only way to address this situation is by asking said CNA. Any suggestions as to how you have handled this?

[Red Kryptonite]

ambitiousblonde said:

Documentation from CNAs on vital signs (not WNL), stating/annotated "notified xxx, RN," and they never actually informed you.

Are you sure they didn't? Several times in the hospital, I tried to notify my RNs, and they didn't make it easy. It got to the point where I stopped trying to tell them face to face (if I could even find them) and would leave a message on their Vocera.

[betweenus64, LPN]

I worked in a nursing home where the CNAs thought they were the nurses and did not listen to their advisors or nurses on staff. They think they own the place if they have been there for any time. At least, this is how I have found some of them to be, maybe not all. CNAs must be reminded to report to their nursing staff before any documentation is done, or they will be let go. I would not put up with any of this one day. This is your *** and your license. If they say, they told you when they did not, who is to prove otherwise? If upper staff will not help you find another job, your license is worth more than this!