The following tips are some general for documentation within a patient’s the medical records:
1. BE DESCRIPTIVE Be sure to describe what you observed and what you did. Include the following: status of the patient; changes in status; care given; communications with physicians; documentation that physician’s orders have been followed; and documentation that policies and procedures have been followed.
2. Always notify your supervisor immediately of any changes identified as new or suspicious and document that you have done so.
3. BE OBJECTIVE Be sure to use objective terms. Record the facts, not opinions or assumptions. Never use the clinical record to vent anger or assign blame. Also avoid recording unnecessary information, such as a statement about staffing; that could be misconstrued in court as having a bearing on a patient’s injury. A staffing shortage, for instance, may or may not have had a direct effect on a patient.
4. BE CAREFUL Be sure to pay careful attention to correctness. Never falsify the clinical record to cover up a negligent act. Fraudulently altering or falsifying the medical record is a crime. See Section 395.302, Florida Statutes. A falsified record can destroy the credibility of the entire clinical record. Not only could this influence the verdict, but a falsification could result in the award of punitive damages and punitive damages may not be covered by malpractice insurance.
5. BE UNIFORM Be sure to be uniform with your institution’s approved abbreviations. AHCA standards and many state regulations require agencies to use an approved abbreviations list to prevent confusion. Know your agencies approved abbreviations. Use of an unapproved abbreviation can cause ambiguity in the records. For example, if you use “O.D.” for “once a day,” another nurse may misinterpret it as “right eye” and mistakenly instill medication into the patient’s eye, instead of giving it once a day.
6. BE METICULOUS Be sure to be meticulous about your charting. When documenting care, use the appropriate form, identify the patient on every page of the form, fill it out in ink, use standard abbreviations, spell correctly, write legibly, correct errors properly, write on every line of a form, and sign each entry with your first name or initial, full last name, and professional license (such as RN, LPN or CNA).
7. BE EXTENSIVE Be sure to document as extensively as necessary. You do not need to chart routine tasks, such as changing bed linens unless it is specified on a plan of care, but you do need to chart relevant, material information relating to patient care and reflecting the care provided.
8. BE NEAT Be sure to document in the patient’s records neatly, so others can read it. Effective documentation requires legible handwriting. Illegible writing may hinder communication between health care professionals.
9. BE TIMELY Be sure to document when events occur. Be specific about time. In particular, note the exact time of all sudden, material changes, significant events and nursing actions. Document pertinent information as soon as possible after an event. Your charting will be more detailed, accurate and clinically useful. Moreover, if you become involved in litigation, you’ll find it easier to defend your actions because prompt charting leaves no question as to when an event occurred. If you can’t document in the patient’s chart at once, note the time when you charted, as well as the time that event occurred.
10. BE MINDFUL Always document and notify your superior if your patient is refusing care or if a POA/caregiver is preventing you from providing care.
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