Do you make these 3 common charting mistakes?
1. Do you chart assumptions and subjective opinions instead of facts and objective observations?
If a patient is in some kind of distress or is clutching his or her chest, do you write “Patient appears to be having breathing difficulties” or “Patient is anxious and uncomfortable”? Uh-oh! You should be recording exactly what you observe—what you can actually see (clutching the chest) or measure (a spike in temperature). You should also record what the patient tells you, verbatim, using quotation marks, so someone else reading the chart knows this is exactly what the patient said, not what you thought was going on. If the patient actually says he or she is having chest pain, you can record that.
“Patient resting comfortably.” How do you know? “Patient did not complain of discomfort or pain.” Now that’s a fact. Avoid using adjectives such as “normal,” “fine,” “good and “well.” Never write “seems to be…” or “appears to be….” These are the types of comments that lawyers love to jump all over. Sounds as if you were…guessing.
If you have a concern about a patient or an order on a chart, write down your concern and sign it. In this case, you’re not trying to pass off something as a fact about a patient; you’re stating the fact that you have a concern, and as a professional, you are expected to be proactive and express that.
Cynthia Dusseault is a professional freelance writer with both a health and an education background. A former medical radiation technologist and elementary school teacher, she realized that no matter what she did, she was drawn to any task that involved writing, so she decided, over a decade ago, to write full-time. Since then, she has written for a variety of magazines and websites including Nursing PRN, National Review of Medicine, University Affairs, Your Health, Education Leaders Today, Today's Parent, Children's Playmate, WeightWatchers.ca and many more.She has written about topics such as asthma, genital herpes, circumcision, teleradiology, body art, learning disabilities and exercise trends, and she absolutely adores the fact that writing—particularly doing the research for the articles she writes—makes her a lifelong learner.
By Cynthia Dusseault