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Nurses are well aware of the standard which states that if a certain matter affecting patient care is required to be charted and is not, the overwhelming presumption is that it may not have been done. Good documentation will help you defend yourself in a lawsuit; it can also keep you out of court in the first place.
1) Check that you have the correct chart before you begin writing
2) Make sure your documentation reflect the nursing process and your professional capabilities.
3) Write legibly
4) Chart the time you gave a medication, the administration route and the patient’s response.
5) Chart precautions or preventive measures used such as bed rails.
6) Record each phone call to a physician, including the exact time, and response.
7) If you remember an important point after you have completed your documentation, chart the information with a notation that it is a “late entry”. Include the date and time of the late entry.
8) Document often enough to tell the story.
1) Do not chart a symptom, such as “c/o pain”, without also charting what you did about it
2) Do not alter a patient’s record – this is a criminal offense
3) Do not use shorthand or abbreviations that are not widely accepted
4) Do not write imprecise descriptions such as “bed soaked” or a “large amount”
5) Do not chart what someone else said, heard, felt or smelled unless the information is critical. In that case, use quotations and attribute the remarks appropriately
6) Do not chart care ahead of time – something may happen and you may be unable to actually give the care you have charted. Charting care you have not done is considered fraud.
Courtesy of NSO Risk Advisor- (1977), Source: http//www.medi-smart.com/documentation.htm
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