John Wooden said that "It's the details that are vital.
Little things make big things happen." In health care, details
are literally vital because they impact a patient's life. For
nurses, such details come in the form of charting and little
mistakes can make big legal problems happen.
In this blog, I will review the importance of clear, concise,
accurate, and timely charting, charting pitfalls to avoid, and good
charting practices so that you can both safeguard patients and
protect yourself from potential liability.
The Importance of Charting
As a member of the nursing profession, you must ensure that
charts present an accurate, clear, and comprehensive picture of a
patient's needs, your actions and interventions, and the
outcome. An exemplary chart will:
Reflect a patient's
Communicate pertinent information to
all health care providers;
Show your application of knowledge,
skill, and judgment;
Demonstrate safe and ethical care;
Comply with legal obligations and
From a legal perspective, it is critical that your chart
satisfies the above in order to establish that you met the standard
of care of a reasonable prudent nurse. A court will review a
nurse's chart to reconstruct critical events, establish time
frames, and refresh the memories of witnesses. If you undertake an
action or intervention, but fail to chart it, a court may infer
that the action or intervention was not performed. Needless to say,
such omissions can significantly undermine the strength of your
Charting Pitfalls to Avoid
There are a number of charting pitfalls which you can avoid.
Below is a chart of such pitfalls and the proactive steps to avoid
Omitting relevant health
or drug information
Inquire about a
patient's food and drug allergies, diseases, and chronic health
Comply with hospital policy with respect to flagging or
highlighting drug allergies
Failing to note action,
intervention, or medication
Record every action,
intervention, and medication in real-time
For medication, note the dose, route, and time
Recording information on
the wrong chart
Assign a different nurse
to each patient
Double-check patients' wristbands
Failing to note a
doctor's orders with the patient's medical information
Failing to document drug
reactions or changes in patient's condition
Consider the potential of an adverse reaction to medication when a
patient reports a change in symptoms
Writing illegible or
Print, do not write,
Be diligent in completing all documentation
Good Charting Practices
Some good charting practices to keep in mind include, but are
not limited to:
Document, record, and note in
Print your notes rather than use
Complete charts in full compliance
with legislation, regulations, and practice standards;
Do not use personal or unapproved
Review and proofread your notes;
Chart with a view to ensuring that
the reader would understand that the patient received adequate and
appropriate care and that your actions were reasonable and
Remember that when it comes to charting, the little things make
big things happen with respect to patient care and professional
The content of this article is intended to provide a general
guide to the subject matter. Specialist advice should be sought
about your specific circumstances.
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