Some Notes on Charting-A Registered Nurse's Perspective
Precise charting of a patient's symptoms and treatment can avoid major problems in the future. As a caregiver, protect yourself!
The importance of charting was covered in nursing school. But its significance was made very personal by an interesting thing that happened to me about two months ago. I received a subpoena to appear in court as a witness for the defense in a lawsuit. Nothing out of the ordinary in that, you say. Well, what I found interesting was that the event happened over five years ago, and I had never met the defendant.
At the time of the incident, I was working as an RN in a busy emergency department. I am sure that many of you can relate to those stressful nights, such as when the patients from a multiple car MVA start arriving at the ED after the bus driver has had a seizure at the wheel. (Trust me, it really happened.) Those are the times that I refer to as "controlled chaos." Those are also the times that most nurses feel that charting is way down on their list of priorities.
Why bother to chart everything?
After all, you have to check vitals and do a physical assessment on each of your patients. This includes assessing the level of consciousness on the patient with the scalp laceration, including doing q10 minute neuro checks. Don't forget to check the circulation on the patient with the obvious deformity of the left knee. Better get a long-leg splint on that one, and recheck the circulation after the splint is on. Be sure to draw blood when you start the IV on the patient with the compound fracture; she'll probably go to surgery tonight. The doctor has ordered Demerol and Vistaril for her pain. Make sure she gets it before going to X-ray, and recheck the vitals. Don't forget to sign the narcotics book. Have any of the doctors seen the patient with the head trauma yet? Better make sure, and better do those vitals q45 minutes instead of q10. Check the charts for any new Doctors' Orders. There goes the radio againâ€¦ eight more coming in! We're going to need to juggle beds. Is there anyone who can discharge now? The list goes on and on.
You have just assessed three of the eleven patients that were the first-wave arrivals in the ER. Blood is drawn, IV's are started, splints are on, and vitals are all up to date. Do another quick assessment before they start going to the X-ray department to see if there are any changes in their condition that need to be reported.
If you don't chart it, you didn't do it.
That's an important caveat. Five years from now, you may be the one who receives the subpoena to appear as a witness for a patient; or worse yet, to defend yourself in a lawsuit. Do you remember what you did and did not do five years ago on the "night from hell"? Do you even remember any of the patients that you provided excellent care for at that time? After all, they were your priority then. By the way, do you remember what you had for lunch last Thursday?
The medical record is what will make or break your defense (and possibly affect your career). When the attorneys start asking you questions as to whether or not you did a certain procedure at the time, it is NO defense to say, "Yes, I did," if there is no documentation to that effect. How do you respond when the attorney asks you to "Show the court where in the chart you documented that"? If it wasn't charted, it wasn't done. And, remember also, that the jury who will ultimately determine your guilt or innocence--that will determine if you are going to pay millions of dollars in damages--is carefully listening to your defense, or lack of same.
If it was important at the time to take vital signs every five minutes, then it should be just as important to chart them in the patient's permanent record. Even if they were consistently within the normal parameters. After all, charting the normal vital signs may be a defense for you later. The patient bringing a lawsuit against you may be arguing that something was wrong at the time, and you ignored her complaints. If you can show that you were attending to the patient every ten minutes, she will be hard pressed to prove that you abandoned or ignored her.
Qualify your charting.
When charting your observations, don't get hung up on medical jargon. If the patient's toes are dusky and cool to the touch, chart that. Add what I call "qualifiers" to your charting. Does the patient have a splint? Did you chart what the toes looked like before splinting? Were the toes dusky and cool to the touch before the splint was applied? Did