"The best offense is a good defense: ' In the world of nursing and malpractice, the best way to avoid having to defend yourself in court is to chart factually and defensively. This involves knowing:
*how to chart
* what to chart
* when to chart
* who should chart.
HOW to chart:
A skilled nurse charts with a jury in mind and knows that how she charts is just as important as what she charts.
Rule #1: Stick to the facts.
Record only what you see, hear, smell, feel, measure, and count not what you infer or assume. For example, if a patient pulled out his LV. line, but you didn't witness him doing so, write: Found pt., arm-board, and bed linens covered with blood. 1. V. line and venipuncture device were untaped and hanging free. If the patient says he pulled out his LV. line, record that.
Don't chart your opinions. If the chart is used as evidence in court, the plaintiff's lawyer might attack your credibility and the medical record's reliability. Chart subjective information only when it's supported by documented facts.
Rule #2: Avoid labeling. Objectively describe the patient's behavior instead of subjectively labeling it. Expressions such as exhibiting bizarre behavior or using obscenities mean different things to different people. Could you define these terms in court?
Rule #3: Be specific. Your charting goal is to present the facts clearly and concisely. Use only approved abbreviations and express your observations in quantifiable terms. For example, writing output adequate isn't as helpful as writing output 1,200 ml. And Pt. appears to be in pain is vague compared with Pt. requested pain medication after complaining of severe lower back pain radiating to his right leg. Also avoid catchall phrases, such as Pt. comfortable. Instead, describe how you know this. For instance, is the patient resting, reading, or sleeping?
Rule #4: Use neutral language. Using inappropriate comments or language is unprofessional and can cause legal problems. In one case, an elderly patient developed pressure ulcers, and his family complained that he wasn't getting adequate care. The patient later died, probably of natural causes. Because his relatives were dissatisfied with the patient's care, they sued. The insurance company questioned the abbreviation PBBB, which the physician had written in the chart under prognosis. After learning that this stood for "pine box by bedside," the jury awarded the family a significant sum.
Rule #5: Eliminate bias. Don't use language that suggests a negative attitude toward the patient, such as obstinate, drunk, obnoxious, bizarre, or abusive. The same goes for what you say out loud and then document. Disparaging remarks, accusations, arguments, or namecalling could lead to a defamation of character or libel suit. In court, the plaintiff's lawyer might say, "This nurse called my client `rude, difficult, and uncooperative.' It's right here in her own handwriting! No wonder she didn't take good care of him." Remember, the patient has a legal right to see his chart. If he spots a derogatory reference, he'll be angry and more likely to sue.
If a patient is difficult or uncooperative, document the behavior objectively and let the jurors draw their own conclusions.
Rule #6: Keep the record intact. Discarding pages, even for innocent reasons, raises doubt in a lawyer's mind.
Let's say that you spill coffee on a page, blurring several entries. Don't discard the original. Rewrite it and put both pages in the chart. Then cross-reference them by writing Recopied from page on the copy and Recopied on page on the original.
WHAT to chart:
Caring for patients seems more important than documenting every detail, doesn't it? But legally speaking, an incomplete chart reflects incomplete nursing care. Leaving out details is such a serious and common charting error that malpractice lawyers have coined the expression, "Not charted, not done." This doesn't mean that you have to document everything. Some information, such as staffing shortages and staff conflicts, is definitely off-limits.
No comments:
Post a Comment