What is most important to chart on?

adventure_rn, MSN, NP · Feb 6, 2019

It depends so much on the situation and patient. At minimum, you should always chart per your unit's policies (i.e. how many assessments and vitals you need to do per shift). That way, if you're ever in a legal setting, you have your hospital policy to back you up. Any time I'm doing something that deviates from the policy at a provider's request, I do everything I can to get an official order, and I'll specifically annotate why I'm not following policy and who (full name, credentials, and provider role) told me not to.

When I'm deciding how thoroughly I need to chart on different circumstances, I will sit and think through "How likely are we to get sued over this?" to make my decision. If I'm noticing a kid's diaper rash, I'm not going out of my way to document that I notified someone; nobody is getting sued over a run-of-the-mill diaper rash. Conversely, if I've got a kid who is very unstable and I'm in constant communication with the medical team, I'm charting on that provider communication at least every hour. That's a kid who is likely to code, and if the hospital gets sued, I don't want someone looking at my record and assuming I didn't notify the provider about the early warning signs.

I also chart more thoroughly if I think it's a family that's more likely to sue. If I've got an angry parent who happens to be a malpractice attorney (yes, I've been in this situation), you bet I'm extra careful with my charting. Similarly, if I've got a kid who has a poor prognosis due to a prior medical complication/error during admission (i.e. bad surgical outcome, hospital-acquired sepsis) where I think the family will have a very strong case to sue regardless of my care, I'm still extra careful with my charting.

It's kind of a triage process. If the likelihood of getting sued is low, it gets a couple of words ("perineal yeast, fellow notified, start nystatin"). If it's an ongoing issue that has the potential to go sideways, it gets hourly documentation ("frequent drops in sats HR/BP/O2 sats with agitation, Dudley Doolittle MD fellow at bedside to eval, precedex bolus x 1 per order.")

If it's a scenario where the likelihood if getting sued is high, it gets a full-blown significant event note ("Patient BP consistently elevated throughout shift with SBP > 150, verified with manual cuff pressure. Dudley Doolittle MD fellow and Susan SmartyPants MD attending notified of elevated BP at 0800 during AM rounds and again q 30-45 minutes throughout shift. Per Dr. SmartyPants, BP elevation is related to neuro storming, no new orders. Patient's neurological assessment unchanged from baseline, no evidence if seizures.") This is a note I had to write from an actual case, and I also charted hourly interactions with the providers ("SBP > 150, Susan SmartyPants MD notified, no new orders"). This kiddo was totally fine before admission but had a bad post-op code and ended up neurologically devastated, so there was a very high risk that we'd eventually get sued. When this infant had consistent BPs in the 170/120s - with a huge risk to stroke out - and nobody wanted to do anything about it, you bet I was charting every single interaction. I'm sure my note looked like I was throwing the providers under the bus. However, if push came to shove, they could have easily thrown me under the bus and say they weren't notified if I hadn't explicitly charted it.

Lane Therrell FNP, MSN, RN, NP · Feb 6, 2019

Develop a systematic approach for the multi-step processes you do routinely (like assessments). When you develop good habits of always doing things the same way in the same order, you're less likely to forget something when things get hectic, and the charting flows easier and quicker.

gonzo1, ASN, RN · Feb 6, 2019

Charting is a big worry for a lot of nurses, including me. There are several books on the subject, lots of information on google and there are even online CEUs and seminars out there.

I'm finally feeling comfortable with my charting after 15 years, so just know that learning how to chart is an ongoing process that really never ends.

I do try to never double chart. If something is addressed one place in the chart by me, I pretty much refuse to chart it anywhere else again.

Somehow, in the documentation that you do try to paint a picture of the patient so that you might recall them easier in the future.

I highly suggest nurse Liability Insurance as well. I've had NSO for my entire career, but there are other companies. You've gotten a lot of good ideas from everyone.

Lololololoollkkgddfuih · Feb 6, 2019

On 2/4/2019 at 12:26 PM, 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.

If you don’t count the patient breaths you will not get into heaven.

Lololololoollkkgddfuih · Feb 6, 2019

Just now, Ron Wallace said:
If you don’t count the patient breaths you will not get into heaven.

CHRIST IS WATCHING.

Lololololoollkkgddfuih · Feb 6, 2019

Just now, Ron Wallace said:
CHRIST IS WATCHING.

STOP TRYING TO CUT CORNERS. There are no secrets to charting, just do it. LEARN TO TYPE FAST.

adventure_rn, MSN, NP · Feb 7, 2019

5 hours ago, Ron Wallace said:
If you don’t count the patient breaths you will not get into heaven.

Why count them? Everybody knows that they're always documented as 18 regardless!

**canoehead, BSN, RN** · Feb 7, 2019

When the poo hits the fan, charting is great, a live patient is better, and a patient and family that feel understood and cared for is best. Chart the facts, but if you have to choose between giving the patient care, or getting the chart right, the patient always wins.

LilPeanut, MSN, RN, NP · Feb 15, 2019

Definitely agree that over charting is a possibility and bad. Especially if that double charting doesn't match exactly.

Advanced Practice Columnist / Guide · Feb 15, 2019

Having worked on both sides of the care team (RN once, NP/provider now), one of the more contentious issues we see on the provider's side is what we call the "MDA" or "NPA" statement. That's a nurse writing MD aware or NP aware on their charting. It's not a bad charting element but use that statement wisely. What you don't want to do is to start a charting war between you and the provider. Remember that a lawyer would look at that and can use that as incriminating evidence against the institution that you as the nurse, and them as the provider, both represent.

If you do write the "NPA" or "MDA" statement in your charting, make sure that it is in the spirit of doing the right thing and that you've closed the loop between that provider you informed as far as agreeing on what the expectations are for further follow up and maybe further phone calls to that provider should that need arise. If you don't get reasonable answer the first time or are not satisfied with the decision of the provider, bring it up to the chain, talk to your charge nurse or resource person and have a game plan. You don't really want your patient to suffer from the consequence of a provider not doing the right thing anyway.

Jory, MSN, APRN, CNM · Feb 15, 2019

On 2/4/2019 at 1:26 PM, 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.

I could kiss you for asking this question!!

Many new grad nurses chart very little in their narrative and that...can come back to bite them.

It sounds like you have the basics covered...you document how you addressed any abnormals, if you called them for anything, changes in medication, the MD you notified, check, check...you are off to a great start!

The rule of thumb, is anything that is covered in your regular assessment, if you have a checklist for skin assessment, alcohol withdrawal, anything otherwise covered where you can chart normals and abnormals...you don't need to include a narrative unless you have performed any intervention from removing 10 blankets from a patient with a low-grade or called for a change of meds...you get it.

But this is where newer nurses do the patient, the physician and the hospital a grave disservice: They don't chart anything about the patient themselves.

"Not in acute distress" doesn't tell me anything. If you walk in and Mr. Smith has had very little to say, seems down, gives one word answers...you try to engage in a conversation he doesn't want to talk...it could be him, it could be he's depressed, tired, sleepy...here is the problem: We don't know.

This is where your narrative comes in: "Finished shift assessment of patient (you don't need to restate your findings as it's already charted), upon entering room, patient with head down, lights dark, declined offer to turn on some lighting or lift shade on window, asked patient questions about how he was feeling today, patient alert, but minimally verbally responsive. No acute distress."

This may prove valuable for the previous nurse that had him the first two days of his stay and he was chatty Charlie...could be an early sign he's fatigued, maybe worsening, depressed, etc. But this documents a TREND in behavior.

Also important: Social issues.

Ms. Johnson is 76 years old, lives alone, and admitted for a UTI and has altered mental status, talking about her dead husband in the present tense, etc. No previous diagnosis of dementia.

I'll go ahead and tell you now..a UTI will easily mimic dementia. You clear the infection and see how it rolls. Let's say Ms. Johnson starts having hallucinations and you go in her room, she thinks she is being held captive in a nursing home and has thrown her food tray. She doesn't know she is in a hospital.

"Patient stated upon entering room, 'I don't want to be here, you can't keep me in this nursing home!' attempted to reorient patient that I understood her concerns, but provided reassurance she had a urinary tract infection we were treating and she was in the hospital, not a nursing home. Assisted patient back in her bed. Patient now calm. Discovered food tray in the far corner of the room near the window, contents on the wall and in the floor. Asked patient how the tray got there, patient stated, 'she didn't know'. Cleaned up contents. Patient stated she is not hungry. Patient declines further needs at this time."

If this seems obvious, it's not. I had that stayed in the hospital two weeks longer than she should have because nurses would not chart ANY of her behavior. Every time a psych pre-screener came to evaluate her after her infection was cleared, there was no documentation...every...single...day. Yet the nurses talked about how she threw things around every day and had hallucinations.

Hope this helps!

LilPeanut, MSN, RN, NP · Feb 15, 2019

@juan de la cruz

I had thought about bringing up the same topic.

It does not protect the nurse to chart just that the "provider notified" if there are truly concerning things that you feel need to be acted on.

In those cases, probably your best bet would be to document an SBAR communication between you and the provider and conclude it with "escalating up chain of command".

If you are concerned with a finding and a provider isn't taking you seriously enough, you have an obligation to keep escalating up the chain.

When I was a bedside RN, I was floated to an ID floor (I'm NICU) I had babies as my assignment, so it was appropriate. One baby with RSV, afebrile, had a HR while sleeping >200. Every once in a while it would abruptly drop to 130s, the return to >200. I called the resident, who told me "babies have higher HR when sick." Uh, yeah, I know, but this isn't normal. I called the charge nurse, who helped me call the resident again, who finally ordered a CXR to appease me - well, for the first time, during the CXR, baby had circulatory compromise (got mottled, blue/gray). When we returned to the floor, again the resident blew me off, saying he was sure baby had just gotten cold. By this point, I had nursing supervisor involved. We finally called rapid response.

I think they admitted her to a higher level of care again mostly to shut me up, but when the cardiologists finally saw her, she had some rare arrhythmia and ended up needing to be on lidocaine and esmolol drips.

I did not know what arrhythmia she had when I called the resident, but I knew for sure that her vitals were abnormal for her condition and age, and so if I just reported the abnormals, then charted that and ***ed about the resident to my fellow nurses, if the baby had gotten into trouble, I would have been liable too. I knew the baby needed to be seen and escalated and as a patient advocate, I had to keep being annoying until someone listened to me.