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The one thing nurses should never assume about charting

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How many times have you heard the phrase “If it wasn’t charted, it wasn’t done?” Simply writing your observations, concerns and actions in the chart, however, isn’t enough to guarantee good care.

Dr. Brady: The example I gave in Part I was for the benign, self-limiting condition commonly known as a cold or a “URI.” But what if the patient in our vignette had something more sinister? What if it was a TIA, and two days later the patient had a stroke and did not have a complete recovery? What if the nurse documented that the patient had transient vision loss in addition to her chief complaint of arm numbness? What if the patient assumed the nurse told this to the doctor but didn’t? What if the patient was sent home, but returned two days later with a completed stroke, and the next doctor who saw her told her she should have never been sent home from her first visit two days prior?

What would this patient think? Whom would she blame for her bad outcome? What if she sued? What would her lawyer think if he looked over the medical records and saw that there were multiple inconsistencies between the documentation of the different doctors and nurses involved in her care?

I’ll tell you what that lawyer would think: “Cha-ching! No evidence of conspiracy in this chart.” The only thing left would be for the malpractice insurers to write the check.

Nurse Rebekah: There is always the risk of being human. Not everyone presents with the textbook symptoms (I really wish patients would!) and not everyone is on his A-game every single day. So we should never assume that the left hand knows what the right hand is doing. (Ever hear the old adage about assuming?!)

If you’re really concerned as a patient, nurse or physician, it never hurts to simply reiterate important information or ideas. I have irritated many a doctor by reminding them of stuff (as in turn, they have irritated me), but if I save a life three of those times a doctor got irritated—well then, mission accomplished.

Never, ever assume that charting a concern is the same as drawing it to a physician’s attention. As important as good charting is—and we’ll talk about that more in Part III of our charting essentials series—patient advocacy always comes first. If you’re worried about your patient, tell someone. You can always chart it later.

Let’s review: Charting is all about communication, and communication is absolutely essential to good patient care. As good as you may be—and we don’t doubt that you’re an excellent nurse—you can’t do it alone. To meet and exceed patient expectations, healthcare providers have to work in harmony with one another.

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 The one thing nurses should never assume about charting

  1. Nicole, RN

    The last paragraph basically sums up the most important concept in the article. We run into many emergency situations where caring for the patient takes extreme precedence over charting in the computer. Once the situation is resolved or the patient is stable, then it is equally important to document everything that happened. During a code, a person who is documenting everything is nearly as important as those who are pushing meds and doing compressions. Relating this to a legal issue, imagine if something out of medical control happened to the patient once they went home and they are trying to blame the hospital for the issue. If nothing is ever documented, there is no proof that care was adequate and appropriate. But if thorough documentation was done then the caregivers can protect themselves through their documentation. Bottom line, although it doesn’t always take immediate priority to alerting doctors and doing procedures, charting is just as important as patient care, just not as urgent.

  2. Rebekah Child Scrubs Blogger

    I totally agree! I am always reminded that the person who came up with the mantra “If it wasn’t charted, it wasn’t done” wasn’t a nurse. It was a lawyer!!!

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