§  Principles of accurate documentation

·         Document significant information objectively

·         Factually include sources of information

·         Document things you see, feel, hear, or smell

·         Document all positive findings that are essential to patient care and diagnosis

·         Document all education/instructions provided to pt and his/her understanding of them

·         Document pt’s response to care provided including worries/concerns

·         Documentation should tell a story and show your thought process

·         Documentation should be time-specific regarding sequence of events

·         Name involved staff

·         Document legibly, spell correctly, use approved abbreviations, use blue/black ballpoint ink

·         Document events ASAP after they occur

·         Use narrative to document information not included on flow sheets

·         Use quotes when appropriate

·         Document late entries appropriately

·         Correct errors properly

·         Sign all entries 

§  Legal pitfalls of charting

·         Incident reports

·         Informed consent       

·         Advanced directives

·         Pts who refuse treatment

·         Documenting for unlicensed personnel

·         Using restraints 

·         Pts who request to see their charts

·         Pts who leave AMA (use the AMA form)

§  Incident reports, managing incidents

·         Do not include incident report when documenting

·         Nurses legally bound to report critical incidents

·         Nurses should know appropriate procedures for completing and filing incident report

·         Describe events objectively, avoid subjective comments/personal opinions

·         Never photocopy incident report

·         MD’s order for incident report shouldn’t be noted in chart

·         Document events of incident clearly, objectively, and thoroughly

·         Physical environment at time of incident should be noted in medical record and incident report

·         State by name who was notified about incident and when

·         Document actions taken on pt’s behalf

·         Document physical assessment of pt with attention to injuries that followed the incident (document if there were no injuries)

·         Do NOT speculate, assume, or assign blame

·         Medication error

o   Document all meds given (correct and incorrect)

o   Document subsequent changes in pt condition

o   Do NOT record in treatment record that med error occurred!

·         Falls

o   Document physical environment at time of fall

o   Document pt condition before and after fall

o   Document subsequent action taken and ongoing assessment

o   Document time of fall and who was notified

·         Treatment complications

o   Document complication completely and objectively

o   Document all treatment given in response to complication