Documenting the care and treatment each patient receives is a primary duty for a nurse. Although some might argue that documentation is not as important as direct care for the patient, proper documentation actually helps the rest of the medical team provide effective treatment. This information is used to plan and adjust a patient's course of treatment and to accurately bill for services. In addition, documentation protects the nurse from malpractice suits. Proper charting is critical to protect the medical facility and nurses from legal action and to provide the best care possible for patients.
Nurses document basic health information, such as the patient's vital signs, complaints, medical tests ordered and their results. In addition, nurses can record symptoms or behaviors they personally witness. These should be objective observations relevant to the patient's health, rather than subjective opinions on the patient's feelings or attitudes. Nurses also record when they administer treatments and medication; physicians orders; and any changes in the patient's status. While a patient's medical diagnosis is an important part of a complete chart, nurses do not make a diagnosis; this is the responsibility of the physician.
Clear and Accurate Entries
Nurses must complete entries using legible handwriting. Charts should include only factual information and not a nurse's opinions. Abbreviations should only be used if approved by the medical facility's policies and must be used consistently. Nurses should document care as soon as possible after treatment, and charts should include the time that care was given.
It is illegal to alter a patient's medical record. If a nurse makes a mistake while writing an entry, the proper way to correct the mistake is to draw a line through the error and sign or initial the change. Do not use correction fluid to erase mistakes. Additionally, nurses must not destroy medical records or make back-dated entries.
Proper charting not only facilitates quality care, but patient charts are also a primary piece of evidence in medical malpractice suits against nurses. Each state has a statute of limitations, or a limited time period during which the patient may file a lawsuit. In Pennsylvania, for example, the statute of limitations is two years. Reviewing the chart allows nurses to recall the case and the actions they took, and also allows attorneys to review the treatment provided to patients. If a nurse fails to accurately complete a chart, she may be found negligent in her duties.
Electronic Medical Records
Some medical facilities use electronic medical records, which require the same proper charting steps as paper records. Nurses must ensure that records are accurate and contain all of the required information. In addition, nurses must protect their access password so that records may not be tampered with. After entering their notes and documentation, nurses must save their work and close the screen to protect patient privacy.