Time for a little refresher on charting! Ask yourself if you make these three common mistakes, and get back on track right away.
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.