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...

 

[DedHedRN]

I work with a nurse that likes to write things such as, "Pt says that Nelly RN told her last night to take 15mg of morphine, and this SN informed them that it's actually for 5mg". "They complained that Nelly RN was rude, and they were not happy with the care from that nurse."

I have been the recipient of this kind of charting. It infuriates me because, for one, I may have never told them to take that much morphine and have no idea why they are associating my name with saying that, and for two, there may be a lot more around the situation, maybe they are mad that they wanted ativan and the doctor couldn't prescribe it, it doesn't mean that I was rude.

So I would add to that list, Don't chart issues you didn't witness!

[toomuchbaloney]

Always document the patient's report of pain with appropriate quantifiers.

Follow that documentation with the nursing response and intervention.

The patient's response to the intervention is the next step in the documentation.

Your documentation is supposed to reflect the nursing care of that patient on your shift.

If something untoward happened and you completed an incident report, you should document that the appropriate management/supervisory staff were notified and that the required documentation was completed. When you are deposed years later, this documentation will assist you in recalling the events of the shift and your responses. Suppose your policy manual requires an incident report, and you document that the required documents were completed. In that case, years later, you can feel confident that you followed policy and can testify to such. Without that, you may be held accountable for something beyond your area of responsibility.

Your documentation should be a concise, accurate, professional record of the patient's condition and the care provided during your shift. No personal or narrative opinions, just the facts, and it is a record AND a tool.

[amygarside]

Great list. Thanks for this post. It would be a great help.

[redhead_NURSE98!, ADN, BSN]

DedHedRN said:

I work with a nurse that likes to write things such as "Pt says that Nelly RN told her last night to take 15mg of morphine and this SN informed them that its actually for 5mg" "They complained that Nelly RN was rude, and they were not happy with the care from that nurse."

I have been the recipient of this kind of charting, and it infuriates me because, for one, I may have never told them to take that much morphine and have no idea why they are associating my name with saying that, and for two, there may be a lot more around the situation, maybe they are mad that they wanted ativan and the doctor couldn't prescribe it, it doesn't mean that I was actually rude.

So I would add to that list, Don't chart issues you didn't witness!

We have a seasoned nurse who likes to write things like "pt complained of being turned so much. Says "you are the only one who makes me turn." "only nurse that cleaned my foley." Etc. That doesn't earn you any awards for Nurse of the Year, sweets.

[redhead_NURSE98!, ADN, BSN]

toomuchbaloney said:

If something untoward happened and you completed an incident report, you should document that the appropriate management/supervisory staff were notified and that the required documentation was completed. When you are deposed years later, this documentation will assist you in recalling the events of the shift and your responses.

It will also assist the patient's lawyer in sinking your ship. An incident report is not discoverable in litigation until someone who doesn't remember what they were taught in nursing school refers to it in the patient's chart. It is fundamental (basic knowledge taught in the lowliest of lowly nursing programs, subject matter for the NCLEX) not to refer to incident reports in a patient's chart.

[toomuchbaloney]

redhead_NURSE98! said:

It will also assist the patient's lawyer in sinking your ship. An incident report is not discoverable in litigation until someone who doesn't remember what they were taught in nursing school refers to it in the patient's chart. It is fundamental (basic knowledge taught in the lowliest of lowly nursing programs, subject matter for the NCLEX) not to refer to incident reports in a patient's chart.

Please note that I did not indicate that you should document that you completed an incident report. If, however, your policy means that there are documents you should complete in the case of a particular event, you may document that you completed the documents per policy. When you are deposed, you need to know, years later, what you did and did not do, as YOU will be held accountable for the chain of command that YOU followed.

I know it is not wise to chart something to the effect that "an incident report was initiated," etc. However, if you follow policy, especially during an unusual and significant incident, your documentation should reflect that policy. Does that make sense?

[sandyfeet]

Nurse acewa said:

Another time I charted that a pt. had SOB and the NP and student NP did not address it at all and instead addressed something else. What should I chart to protect myself from situations like this in the future?

What I would chart is something like "Patient complains of SOB. (further explanation of current respiratory symptoms) NP notified. No new orders at this time."

In my ED we were recently taught to stop writing "Floor nurse says she is too busy to take report and asks RN to call back" as it was considered inflammatory and potentially litigious. After reading this article it seems all the more obvious, but at the time, with management sweating us out over "why does it take so long for patients to get transferred up?", writing a note like that felt good. We now use a different system that can reflect a delay on the floor's end in taking report without spelling it out like before.

[redhead_NURSE98!, ADN, BSN]

\ said:

Please note that I did not indicate that you should document that you completed an incident report. If date=,' however, your policy means that there are documents you should meet in the case of a particular event, you may document that you completed the documents per policy. When you are deposed, you need to know, years later, what you did and did not do, as YOU will be held accountable for the chain of command that YOU followed. I know it is not wise to chart something to the effect that "an incident report was initiated," etc. However, if you follow policy, especially during an unusual and significant incident, your documentation should reflect that policy. Does that make sense?

It does, up to the point that you're in a deposition. "Documentation completed. What documents were you referring to?" Now your incident report is referred to anyway and subject to discovery, in the middle of litigation no less.

[toomuchbaloney]

redhead_NURSE98! said:

It does, up to the point that you're in a deposition. "Documentation completed. What documents were you referring to?" Your incident report is referred to anyway and subject to discovery during litigation.

In my depositions, I refer them to the medical record and documents acquired during discovery, and I don't have to remember which documents specifically. My charting indicates that I followed the policy, implying that I was aware of the procedure and used it to direct my actions on behalf of the patient. The attorney may then attempt to prove that I did not follow said policy, but that becomes an uphill battle.

Given that incident reports are not a portion of the medical record, it is unlikely that they are part of the court proceeding. Given that multiple documents are present in any unusual event in the healthcare setting, there is nothing uncommon about a comment of this nature.

If you are uncomfortable with this, you may indicate that you followed policy or reviewed with a superior or other indication that you completed appropriate steps. It's up to you.

Our employers do not want us to make things difficult for them in these situations. However, they will allow you to take the fall in many cases.

[SoldierNurse22, BSN, RN]

redhead_NURSE98! said:

We have a seasoned nurse who likes to write things like "pt complained of being turned so much. Says "you are the only one who makes me turn." "only nurse that cleaned my foley." Etc. That doesn't earn you any awards for Nurse of the Year, sweets.

True, but wouldn't you like to have it in the medical record that the patient was c/o poor standards of care to everyone when they were adequately cared for, AEB, your fellow RNs' notes?

I don't chart that the patient said XYZ about Nelly RN because I think Nelly is a nasty nurse. Like an accurate pain assessment, I chart it because, just like when a patient gets mad and swears, that's what the patient said.

If Nelly (and all the other RNs) did their charting correctly, it should state in the notes that she told the patient to take 5mg Morphine, not 15mg Morphine. And how confusing would it be if you did have a patient who took 15mg Morphine instead of 5, and no one bothered to get an explanation as to why because they were trying to cover another nurse behind? That isn't right, either.

[systoly]

SoldierNurse22 said:

True, but wouldn't you like to have it in the medical record that the patient was c/o poor standards of care to everyone when they were adequately cared for, AEB, your fellow RNs' notes?

I don't chart that the patient said XYZ about Nelly RN because I think Nelly is a nasty nurse. Like an accurate pain assessment, I chart it because, just like when a patient gets mad and swears, that's what the patient said.

If Nelly (and all the other RNs) did their charting correctly, it should state in the notes that she told the patient to take 5mg Morphine, not 15mg Morphine. And how confusing would it be if you did have a patient who took 15mg Morphine instead of 5, and no one bothered to get an explanation as to why because they were trying to cover another nurse behind? That isn't right, either.

It might protect Nelly as well.

I have charted what a pt. stated about Nelly several times

Only Nelly wasn't even on duty during the shift in question

[redhead_NURSE98!, ADN, BSN]

SoldierNurse22 said:

True, but wouldn't you like to have it in the medical record that the patient was c/o poor standards of care to everyone when they were adequately cared for, AEB, your fellow RNs' notes?

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.