What is most important to chart on?

Ruby Vee, BSN · Feb 4, 2019

8 minutes ago, Red_Diamond said:
I know my question seems a little ridiculous because as nurses we are supposed to be charting everything we do. I couldn't think of a concise way to word my question. I am a new nurse just off of orientation and I've been very anxious about the whole idea of getting sued or named in court in a case. I know that proper documentation is supposed to "cover your butt" in case this ever were to happen. I'm just wondering what specifically do you make sure to chart at the end of a shift, or if something happens? As a new nurse, I feel like I always leave work with the feeling that I've either forgotten to do something or chart something. I always look over my charting before I leave, but I still am reluctant. I always make sure to document if I've notified the provider for a change in status. Is there any other specific things that you make sure to chart to save yourself in case ever being in a lawsuit? I know i'm probably freaking out too much, but I'm very new and these thoughts have been making me extremely anxious. I've read that nurses can go to court for a patient they've cared for years and years ago. Thanks for your input.

Lawsuits aren't as common as you might think. These days, hospitals, especially big hospitals, usually settle before it gets that far. Still, I'd hate to have to remember a patient or an event without adequate charting . . . .

When you first assess a patient, note anything that isn't normal or isn't the patient's norm. For instance, you cannot chart pedal pulses because the patient has an AKA. (Too many folks just chart the pedal pulses anyway -- it's easy to click that box.). Note the AKA -- now it's the patient's norm. Say you're listening to heart sounds and they're muffled today when they weren't yesterday. After you clean out your "ears" (and maybe your ears), listen again. Still muffled? Document. And then document who you notified and what was done. Don't chart "Heart tones muffled, HO aware." Chart the name of the house officer you spoke with, and what specifically is going to be done.

Chart to exceptions in plans as well. Our standard care plan for a valve replacement involves ambulating three times a day. My patient had an AKA and his wife had taken his prosthesis home. After an angry intensivist wrote a scathing note in the patient's chart about the "lazy nurse who didn't ambulate the patient AS ORDERED" I learned to cover my posterior by NOT checking the "ambulate" box and dashing off a quick exception note that "Pt unable to ambulate until his wife brings his left leg prosthesis in, PT consulting for alternative ways to exercise."

Of course you'll chart anything untoward that happens -- the patient that went into AF, for example -- who you notified and when, what exactly you notified them of, what you're doing about it.

You're new. This is all new. I get it. We all do. In time, you won't have to struggle so hard to remember what to chart. Keep a brain sheet on you, and note things that need to be documented (and the time) as they occur. That will help.

Golden_RN, MSN · Feb 4, 2019

Just remember that you can't over chart. It sounds great that you make time to review your charting at the end of your shift. You won't always have time to do that, and remember to chart all through your shift as things are happening. You never know when that emergency will happen right before shift change!

Your question is way too broad to answer on a message board, and depends on many factors. It sounds like you are very conscientious and double checking your work, so you are probably doing great.

JadedCPN, BSN, RN · Feb 4, 2019

I agree with what the above posters suggested.

Just a couple things that stand out to me for charting - it is important to chart the whole picture if you can. For instance for a patient that refused a medication or treatment - don't just chart "pt refused medication/treatment." Chart that the pt refused the medication/treatment, that you educated them on the importance of said medication/treatment and the risks of not receiving med/treatment, and that they still refused after education, then document exactly which provider you notified and what their response was, even if it is "no new orders."

I also want to stress the importance of documenting exactly who you notified, not just that you notified the "on call doctor." Get first name, last name, and credentials. This goes a long way and provides "credibility" that you did indeed notify a doctor about XYZ.

JKL33 · Feb 4, 2019

1 minute ago, Golden_RN said:
Just remember that you can't over chart.

Sure you can! To the extent that you aren't spending a good portion of your time actually assessing your patient and using the nursing process. And that's without even addressing all the literal double-charting traps we fall into.

***

OP, yes there are lots of situations where the nurse wants to convey a particular detail in order to show that prudent nursing actions were taken. Multiple situations.

But I think it would be helpful to go back to the beginning and then work your way forward. A medical chart is, at its simplest, a concise and accurate record of that patient's conditions and interventions and responses. In other words, it's so there is a record for the patient's and providers' benefit.

Overly-simple example:

A patient goes to the physician and receives a wellness exam at which he receives an immunization as part of health maintenance. Why would this be recorded into a chart? Is it primarily so that, if something bad happens to that patient 5 years from now, no one will blame the doctor for not recommending the immunization? No - that isn't the primary reason. The primary reason is so that the patient and others who are (or subsequently will be) involved in his care understand that on X date he was in general good health and on X date he received that particular immunization.

My point is that the primary utility of keeping a record related to someone's health is so that there is an accurate record of their health experiences that can be used by the patient and others to further that patient's future health.

Now. There are indeed other external forces that have very heavily influenced and greatly expanded the basic premise. Namely: Concern about the potential for future litigation, and concern about reimbursement. Much of what we are demanded to document these days is actually related to the latter of these two things. But we also sometimes spend a lot of time trying to defend against boogey-men (rare outlier scenarios, such as a major lawsuit), and trying to defend against any other random person's dishonest claims (for example, a nurse who says she never received report from you and gets away with that claim because you didn't specifically document that you did indeed give report).

You do have to prudently document what happened in a way that makes it clear that you acted in a prudent manner. But it is a fool's errand to think you can cover every possibility. There was a thread months ago where we were joking around but were able to illustrate that, no matter how much you chart, some malicious person could claim imprudence by, well, being malicious - - trying to twist that which is very clear, etc.

You can't spend your nursing life focusing on boogey-men instead of patients. ? I would even posit that you are more likely to encounter a boogey-man if you focus on documentation instead of patients.

Start with the overall idea of documenting the elements that show the nursing process. These convey the patient's situation/issues, the interventions, and their responses. Add in brief documentation about interactions that took place to facilitate patient care. Concisely document situations that are alterations/out of the ordinary, etc.

If your patient is experiencing a particular difficulty, that's where your actions (and documentation of them) become especially important. Your actions in the patient's best interest remain the primary thing, though. For example, is it important to faithfully document a patient's hypotension every 15 minutes for 3 hours, or is it important to prudently perform the nursing process? Note hypotension, assess patient, present findings to provider, receive orders, intervene, reevaluate, and then, if desired outcome not achieved, repeat the process. Yes, you have to quickly and concisely document those things along the way, but not fret about writing every breath you took at the expense of caring for the patient.

The record is about the patient's health. You fill in extras here and there that convey prudent nursing action.

brownbook · Feb 4, 2019

I can't love JKL33's post enough.

I've been a nurse 35 years in 3 different hospitals and always in the float pool. So I've met a lot of nurses in a lot of different units. I have never met a nurse who was sued or in a court case. I've never even heard a rumour of this happening to any nurse in a facility I worked in.

Of course it happens, I wonder if a stressed rushed nurse worried about keeping up with her charting was a factor in the error.

I'm a terrible "charter". I will spend 10 to 20 minutes at my patients bedside even if they just want to talk, then rush through some of the worst charting you can dream of at the end of my shift.

To be blunt I'd rather leave my shift with a well cared for patient than a perfect chart.

RNperdiem, RN · Feb 4, 2019

Jkl33, This is the best explanation I have ever read about charting on this site.

I also abide by the idea that charting has an ongoing function. For example, in my unit, fluid status is very important. I make sure these are accurate and updated frequently. Treatment decisions the doctors make about diuretics depends on nurses charting of intake and output.

Passing on useful information that you forget to say in report should be right there in the chart. It is a useful thing to know when the patient last moved his bowels, how many days he has had that IV, etc.

dudette10, MSN, RN · Feb 4, 2019

I worked acute care floors, and I became a master at documentation. Determining what was necessary for the care of my patient and skipping everything else. The following was my standard routine. Of course, any significant events would be charted.

Do and chart a complete H2T at the start of your shift. Know what you EHR considers "WNL" and chart exceptions only. Charting normals is a WASTE OF TIME. My unit required a second assessment to be documented. I did the assessment, but I did not waste time with the full H2T click boxes again. I documented changes from my previous assessment, if any. Then, I created a SmartText that essentially stated changes from first assessment were documented in the flow sheet.

The office RNs want you to fill out extra paperwork for their audits with info already charted on the EHR as part of your normal documentation? Screw that. They can do the audits themselves.

Chart pt-stated reasons for refusal and education interventions for those refusals.

Chart the name of the RN you give or receive report, especially during transitions of care.

Charting education in that stupid and unwieldy education module of the EHR is just for the Informatics and Reporting team. I know it's important during audits and everything, but it's a waste of time. Get in the habit of educating your patient on meds as you give them, on procedures as they are ordered, and then you can safely and truthfully create a SmartText on your usual education routine to drop into your end-of shift note.

Make your After Visit Summary actually useful to your patients with written education on home care and times they should take their next doses of home or new medications. Go over it with them prior to discharge. Have them sign it. Your documentation is complete....no need to re-document what the system will save anyway.

There are others, but those are my main time savers that provided accurate and complete documentation for the care of the patient....not the care of the Informatics team.

Serhilda, ADN, RN · Feb 5, 2019

A good rule of thumb I tend to follow is that if something was worth calling the provider about at night, be it the on-call NP or sleeping doc, it's probably worth charting too.

Also, if I document a change in status, I make sure to also document who was notified, specifically what was done, and the patient's response.

LovingLife123 · Feb 5, 2019

22 hours ago, Golden_RN said:
Just remember that you can't over chart. It sounds great that you make time to review your charting at the end of your shift. You won't always have time to do that, and remember to chart all through your shift as things are happening. You never know when that emergency will happen right before shift change!
Your question is way too broad to answer on a message board, and depends on many factors. It sounds like you are very conscientious and double checking your work, so you are probably doing great.

Yes you can over chart. It can be just as dangerous as undercharting.

ruby_jane, BSN, RN · Feb 5, 2019

When I was a new nurse what was most helpful to me was reviewing the charting immediately before mine. I would catch phrases that made sense and steal them. You will get better at this, I promise.

Daisy4RN · Feb 5, 2019

Refer to your facility for "important" things to chart. Some have different preferences so make sure to chart whatever they audit. Also, chart anything out of the patient norm, who you contacted (always notif MD if anything out of the pt norm), what MD said/ordered, and what you then did. Chart refusals and any/all pt Ed. You will learn as you go what is important and what is not, follow up with you educator or charge RN if you have questions. This skill will soon become second nature!!