Practice defensive charting
Nurse Leader Insider, October 23, 2019
Want to receive articles like this one in your inbox? Subscribe to Nurse Leader Insider!
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
Editor's note: This excerpt is adapted from Quick-E: Charting, a part of the Quick-E series. For more information about HCPro's latest nursing resources, click here.
Want to receive articles like this one in your inbox? Subscribe to Nurse Leader Insider!
Comments
0 comments on “Practice defensive charting ”
Related Products
Most Popular
- Articles
-
- Don't forget the three checks in medication administration
- Residency coordinators’ responsibilities
- Study: Shorter shifts reduces residents’ attentional failures
- RPA Subscriber Exclusive: February issue of Residency Program Alert now available
- Practice the six rights of medication administration
- The consequences of an incomplete medical record
- Editor’s note
- Note similarities and differences between HCPCS, CPT® codes
- Nursing responsibilities for managing pain
- Q&A: Primary, principal, and secondary diagnoses
- E-mailed
-
- Use modifiers -59, -91 to "explain" duplicate codes
- Unclear documentation fuels ongoing challenges in assigning appropriate POA indicator
- Tim Porter-O'Grady sounds off
- Skills of effective case managers
- Q: Can you clarify the reporting of dates on the plan of care for diagnosis onset and exacerbation?
- Q&A: Are colleges sending students to our facility for rotations business associates?
- OSHA HazCom updates include labeling, SDS requirements
- Note similarities and differences between HCPCS, CPT® codes
- Fracture coding in ICD-10-CM requires greater specificity
- Five ways to safeguard your patients' valuables
- Searched