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How to avoid lawsuits with smart charting

doctor-charting

Image: Wendy Hope/Stockbyte/Getty Images

In Part III of our charting essentials series (scroll down for links to all four articles), Dr. Brady and Nurse Rebekah show you how acting harmoniously can improve patient satisfaction—and protect you in court.

Dr. Brady: What should have been done for our patient with the TIA in Part II of our Charting series? In terms of care, communication and charting, everything would have gone much better if all the providers had been acting in harmony.

If the nurse and doctor shared all the relevant information, perhaps the patient would have been admitted and the stroke avoided. Even if the stroke still occurred, if everyone had worked and charted consistently, the patient may have at least felt that everything that could have been done was done and it was no one’s fault.

Or even if she did blame someone and hire a lawyer, the lawyer would have subpoenaed the chart, and after looking it over, realized that she received good care and advised her to drop the lawsuit.

Nurse Rebekah: I love conspiracies, but more like the kind that say the moon landing was fake and that the government is listening to our cell phone conversations.

I certainly don’t live in fear of lawsuits. I’ve been to court—it wasn’t fun, the food is horrible and the parking is worse—but I KNEW I gave the best nursing care I could. Even better, I KNEW I had charted pretty darn well. You know who came up with the saying “If it wasn’t charted, it wasn’t done?” Lawyers. When you do your best, you don’t worry about lawyers and judges, and you don’t feel bad about yourself or your work ethic. So chart consistently, according to your standard of practice, and avoid mistakes and self-esteem issues. Seriously, it will save you a ton of money in psychotherapy.

Take the harmonious tack a bit further by learning how to conspire with the rest of your team. Dr. Brady and Nurse Rebekah discuss the importance of choosing your words in Part IV of our Charting Conspiracy series.

Spoiler: You get to decide how you tell the truth.

Usually, we try to tease you with a little information, just enough to encourage you to read the entire article. This time, though, the message is so important that we gave it to you up front: You get to decide how to tell the truth.

The Essentials of Nurse Charting

Part 1: The Secret of Successful Charting

Part 2: The One Thing Nurses Should Never Assume About Charting

Part 3: How to Avoid Lawsuits with Charting

Part 4: How to Choose the Right Words When Charting

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Brady Pregerson, MD

Brady Pregerson, MD, a returned Peace Corps volunteer and winner of the 1995 Wise Preventive Medicine Scholarship, completed his medical school at the University of California, San Diego, and his residency at Los Angeles County General Hospital. He has authored three medical pocket books for nurses and doctors, as well as the educational web sites erpocketbooks.com and gotsafety.org. Dr. Pregerson currently works as an emergency physician in Southern California. He writes, "Although the ED environment may be quite different from working on the hospital floor or in an office setting, I am hopeful that you can take these tips and apply them to your own specific work situation." You can buy his books on lessons from the ER, including Don't Try This At Home: Lessons from the Emergency Department and Think Twice: More Lessons from the ER, at amazon.com.
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2 Responses to How to avoid lawsuits with smart charting

  1. Yasmin

    Chart chart chart to protect yourself! I think depending on the computer system that your hospital uses, some means of charting are actually very efficient in getting information from person to person throughout the days more accurately than by word of mouth at times. Similar to that childhood game, telephone, sometimes information gets skewed from one verbal report to another. Once something is documented, it is set in stone in the chart and all medical personnel have access to that. In an efficient charting system, something that the nurse may forget to pass on in report can be picked up by the incoming resident because it is in the chart. Charting enhances communication but should not act as a sole means but as a cohesive addition to verbal communication.

  2. nursebetty12

    Someone said on a previous post “Whoever said if it wasn’t charted, it didn’t happen must have been a lawyer.”
    I would have to disagree. Whomever made the statement “If you didn’t chart it, it didn’t happen” was likely a nurse or Dr who defended themselves to death in court on a case that should have bern won but was lost due to poor documentation. Good pearls like these come from good, experienced nurses! Not attorney’s!!

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