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In the mix: Practice defensive charting

Stressed Out Nurses Weekly, May 26, 2008

By defensive charting, we mean protective. Who are you protecting? With proper documentation, you protect your patient and yourself. Chart only what you see, hear, feel, measure, count, and experience; not what you suppose, infer, or assume. Chart as if the words you write reflect the actual and complete record of the care rendered, because they must. Chart as if every word could one day be scrutinized in a court of law, because it can.

Be familiar with institutional requirements and clinical protocols (i.e., "assess and document every hour a patient is on restraints"). However, keep in mind that there seldom are concrete "rules" about how long, how often, or what exactly you should chart. Remember, nursing is a science, thus the importance of clinical skills, but nursing is also an art, and like any art, your charting will develop and improve with practice. Here are some key words to help you review and evaluate your charting. 

Ask yourself, is my charting:

• Chronological
• Comprehensive
• Complete
• Concise
• Descriptive
• Factual
• Legally aware
• Legible
• Objective
• Relevant
• Specific: uses exact measures such as "3 cm"
• Standard and consistent with abbreviation and symbol usage
• Thorough
• Timely

Mastering the lingo of a nursing assessment is often challenging, too.

This excerpt is adapted from Quick-E: Charting, a part of the Quick-E series. The 12 new editions, with a revamped look and updated information, will roll off the presses next month. Head over to our Web site to check out the rest of the article.

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