When you decided to become a nurse, you probably didn’t think you would spend most of your time charting. We became nurses to take care of people and to make a difference, not spend hours of the day in front of a computer clicking boxes or doing paperwork.
However, as we’re seeing more headlines about nurses facing felony charges from the Attorney General’s office, it bears reminding all nurses and healthcare professionals just how critical charting is to the well-being and safety of every patient we touch.
The task of documenting can be dull, repetitive, and at times, downright frustrating – yet it is a vital part of patient care. The medical record is essential for several reasons, and documentation is one of the most important parts of our practice. The primary reason for the medical record is that it provides access to data to deliver appropriate care. It allows the healthcare team to track all the care that has already been completed for the patient. Medical records are also used to code services and generate a bill for those services. It may be used to review processes and develop improved policies. For better or for worse, a patient’s medical record may become a legal document accessible in a court of law showing what was done (or not done) properly in the patient’s care.
As much as we commiserate around our shared dislike of charting, we must also appreciate the fact that proper charting practices protect our license, our livelihoods, and our patients’ lives. We all know that mantra ingrained in us from the very beginning of our nursing education; “If it wasn’t documented, it wasn’t done”.
Charting can be used for or against you in a court of law or in front of the nursing board. In most states, providing inaccurate or false Information in a medical record can be a five-year felony conviction. Incompetence and inaccuracy could also result in board actions including reprimand or censure, probation, license suspension, and/or license revocation.
At best, nursing documentation is a useful tool for communication; at worst, it is a necessary evil. Nurses must always ensure that what they add is accurate and compliant with facility guidelines AND state nursing board guidelines. Never chart something you don’t remember or didn’t do – that is considered fraud.
There are standards for nursing documentation that are applicable in all patient care settings and in both paper and EMR systems. These standards include the following:
While I was a nursing instructor, I constantly reminded the LPN students that honest and accurate documentation is one of the most important aspects of nursing. It is the only thing you must show the care that was provided. In the dreaded event of a legal problem, medical records are usually the primary source of evidence for malpractice or neglect claims. They will be scrutinized for every detail, so accurate and complete documentation is your best friend. Your career, and more importantly, a patient’s care and life depend on it.
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