Practice defensive charting

Nurse Leader Insider, October 23, 2019

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.

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