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02.01 Legalities of Charting

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Overview

  1. Legalities of charting
    1. Follow state/facility policy/procedure
      1. Prevents scrutiny/innacurate perception
        1. Of accurately delivered care
          1. Event of legal case
  2. Important
    1. ALL documentation are legal documents
    2. Know your audience
      1. Healthcare team members
      2. If legal case
        1. Lawyers
        2. Experts
        3. Non-nursing jurors
    3. You are documenting for you!
      1. Memory or refresher of events
        1. Litigation up to 2 years
    4. Provide clear/accurate picture
      1. Illustrated timeline of care
      2. See guidelines below

Nursing Points

General

  1. Guidelines for charting
    1. Do
      1. Accurately describe all unusual occurences
        1. Masking existence – red flag
      2. Avoid language
        1. Defensive
        2. Argumentative
        3. Vague
        4. Accusatory
      3. Avoid direct disagreement with provider
      4. Document evidence of patient noncompliance
      5. Ensure late entries follow facility policy
    2. Do not
      1. Understate patient’s condition
        1. Document objectively
      2. Place blame in charting
      3. Become complacent
        1. Check-off assessments
      4. Document your opinion
      5. Use unapproved abbreviations
    3. Always document
      1. Acute abnormality found
        1. Document intervention initiated
      2. Intervention initiated
        1. Document patient response
      3. Patient/family concerns
        1. With follow-up
      4. Patient’s baseline mental status
      5. Patient assessment at discharge/transfer
      6. Clearly, completely, concisely
      7. Sources of information
        1. Other than patient

Nursing Concepts

  1. Clinical judgement
  2. Ethical and legal practice
  3. Professionalism

Reference Links

Study Tools

Video Transcript

Hi guys!  I want to talk to you a little bit about the legalities of charting and documentation and why this is important to you as a nurse!

With charting it is so important that you are always following state and your own hospital or facilities policies and procedures…..with everything and this includes their policies on charting!  Guys this ensures that you will have the backing of higher entities if a legal issue ever occurs. When you chart the correct way or legally you will prevent scrutiny of your charting and also an inaccurate perception.  So what do I mean by this? Ok guys so imagine you have taken care of a patient and you did absolutely everything right and you delivered care to your patient accurately but if you didn’t chart something accurately or you didn’t follow the charting guidelines of your institution it allows, for instance, lawyers, to question your care just because something wasn’t documented the way it should have been.   So yes charting absolutely matters!


Ok so first off you have to know that ALL documentation when you are caring for a patient are considered legal documents.  Also, guys when we are talking about the legalities of charting it is important to know who your audience is, of course, it is going to be other healthcare members who are involved in this patients care but it could also be lawyers, experts, and non-nursing jurors if this case goes to litigation.  Guys, I know this isn’t something that we like to think about as nurses but it is the reality and it does happen to the best of nurses! And I just want to point out if a case goes to litigation it doesn’t necessarily mean its because of something you did wrong, it could be for a completed unrelated issue but you must know they will question everyone who was involved as well as take a microscope to your charting.  So with that said “You are documenting for you!” meaning this will be a memory refresher of events because sometimes litigation won’t occur for 2 years! And when all else fails….always, always provide a clear and accurate picture of your patient…you can never go wrong with that!

In the next couple of slides, I want to give you some tips or the dos and don’ts of charting.  Ok guys always describe unusual occurrences as accurately as possible masking the existence of something unusual can send up a red flag for those scrutinizing your charting.  Avoid defensive, argumentative, vague and accusatory language in your charting. Avoid a direct disagreement with a provider, make sure you document any evidence of patient noncompliance.  Finally, guys, if you have to make a late entry with charting make sure you know and are following your facilities policy because of the timing of entries especially with the EMR, is definitely looked at closely.

A few more tips.  Do not understate a patient’s condition and do not become complacent with your “check off” type assessments be sure what you are checking off is actually the truth. Be sure you are not documenting your opinion although you as a nurse definitely matters when it comes to the chart we do not document opinions information is always objective.  Be sure you are using abbreviations that are approved…remember again these are legal documents. Finally, guys do not place blame in a chart. 

Couple more tips for you all.  I think you probably are starting to get the picture of the legalities of charting but make sure you are documenting acute abnormalities which goes along with unusual occurrences and with the acute abnormalities be sure to document the interventions that were initiated and with that you must document the patient’s response to the interventions.  Always document the patient as well as family concerns along with follow-up. Sometimes patients are not able to provide accurate information so in this case, be sure to document who is providing the information if it is not the patient. Finally, guys if you are documenting clearly, concisely, and completely you have nothing to worry about!

Let’s do a quick review!  Legal charting prevents scrutiny.  Be sure to follow state and facility guidelines.  Remember all documents are legal documents. Be sure you know your audience, provide a clear and accurate picture, remember you are documenting for you as a memory refresher from a case that might have been from years ago!  As far as guidelines always document unusual occurrences, avoid defensive language, opinions, blame, and use approved abbreviations. Always document that interventions were applied, responses to interventions, document clearly, concisely, and completely.

A few nursing concepts we can apply to the legalities of charting are clinical judgment, ethical and legal practice, and professionalism in these are all critical when charting as a nurse.

We love you guys! Go out and be your best self today! And as always, Happy Nursing!

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