Proper nursing documentation will, most importantly, ensure that your patients receive the highest quality and

correct care in response to their symptoms. Legally speaking, proper nursing documentation will help you defend yourself in a malpractice lawsuit, and can also keep you out of court in the first place. The following excerpts are courtesy of NSO Risk Advisor-January, 1977:

Do's
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Check that you have the correct chart before you begin writing. Make sure your documentation reflects the nursing process and your professional capabilities. Write legibly. Chart the time you gave a medication, the administration route, and the patient's response. Chart precautions or preventive measures used, such as bed rails. Record each phone call to a physician, including the exact time, message, and response. Chart patient care at the time you provide it. If you remember an important point after you've completed your documentation, chart the information with a notation that it's a "late entry." Include the date and time of the late entry. Document often enough to tell the whole story.

Don'ts
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Don't chart a symptom, such as "c/o pain," without also charting what you did about it. Don't alter a patient's record - this is a criminal offense. Don't use shorthand or abbreviations that aren't widely accepted. Don't write imprecise descriptions, such as "bed soaked" or "a large amount." Don't chart what someone else said, heard, felt, or smelled unless the information is critical. In that case, use quotations and attribute the remarks appropriately. Don't chart care ahead of time - something may happen and you may be unable to actually give the care you've charted. Charting care that you haven't done is considered fraud.

Documentation should include the following (Charting Tips):

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Direct quotations from the patient, family or visitors Data that has been gathered Actions taken Individuals notified about concerns and issues Evaluation of Actions First, making sure you have the correct chart (MOST IMPORTANT PRIORITY) Writing neatly and legibly (with blue or black ink) Conveying significant details Signing and dating every entry

Legal Aspects of charting should include:

y y y y

Using proper spelling, grammar and appropriate medical phrases Using authorized abbreviations only Assuring patients name is on every page A single line through entry errors and your initials (no erasing or white out)

Nursing documentation and progress notes that are filled with misspelled words and poor grammar create a negative impression. Readers (lawyers and jurors) may infer that a person with poor spelling and grammar is uneducated and careless. The following are true examples of spelling errors noted on nursing flow sheets:
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MD order: Walk patient in hell. Patient lying on eggshell mattress. Fecal heart tones heard. Patient observed to be seeping quietly. Foley draining fowl smelling urine.

The following are true examples of errors in grammar and incorrect use of words noted on nursing flow sheets:
MD order: May shower with nurse Patient has no rigor or chills, but husband states she was hot in bed last night Large BM up walking in the hall Patient had a cabbage done The pelvic exam was done on the floor Vaginal packing out, Doctor in Skin Somewhat pale but present In addition to taking care to use appropriate grammar and use of words, it is also important to avoid writing inappropriate comments on the nursing flow sheet. Finger pointing and accusations of incompetence are surely a red flag to lawyers and jurors. Evidence of fighting among healthcare professionals in the nursing documentation is just what a plaintiffs lawyer is looking for. The following are true examples of inappropriate comments found in nursing and physician documentation:
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IV infiltrated because nightshift forgot to check it Patient going into shock, could not reach Dr. Jones per usual Physician Note Once again, the lab forgot to draw the patients PTT this am Physician Note If the nurses would learn to read medication orders, we would have a lot fewer emergencies around here Patient received insufficient care today because nurse patient ratio was 1:7 Physician Note: Patient fell due to lax nursing supervision Patient in extreme pain because previous nurse too busy to give pain meds

The Risk of abbreviating in legal documentation:

When documenting, its imperative that you dont put your patients life at risk because of the abbreviations that you use. Abbreviations can be extremely dangerous to you and your patient, besides being a major waste of time. The following are reasons why you should avoid abbreviations:

Abbreviations can be a total mystery to the reader. If a physician wrote, Patient may get up AFAWG, would he have communicated with you? How much time would you have to spend trying to figure out what he meant? If you and two other nurses looked at this order for 90 seconds each, four and a half minutes of patient care time would have been wasted. Plus you probably still wouldnt have the correct answer. (For the record, this was a physician order and AFAWG means As far as wire goes). Abbreviations are easily confused. Patients are still being overdosed with insulin and heparin because people use u for units. Another critical error can occur with the use of ug, for microgram, which has been misinterpreted to mean mg, for milligrams. Errors such as these occur more frequently then we would like to admit, and all because someone used and unclear abbreviation. The less space you have for documentation, the more inclined you may be to abbreviate. Make sure that there is adequate space on your flow sheet for your documentation. The tendency is to force a lot of information into small spaces, thereby avoiding having to document in the progress notes. The results are often creative or imaginative but useless, wasteful, and uncommunicative. JCAHO Standard for Approved Abbreviations: It has been reported that as much as 15% of the medication error reports received by the NCC MERP (National Coordinating Council for Medication Error Reporting and Prevention) have occurred because of illegible handwriting, problems with leading and trailing zeros, misinterpreted abbreviations, and incomplete medication orders. To "improve the effectiveness of communication among caregivers," JCAHO is requiring facilities to develop their own list of abbreviations, acronyms, and symbols that should not be used. In addition to facilities individual choices, JCAHO has published a list of unapproved abbreviations that must also be adopted. The following chart includes the JCAHO unapproved abbreviations list which gives suggestions, mandates and expansion options:

Unapproved Abbreviation > and <

Intended Meaning

Misinterpretation

Correction

Greater than and Less than microgram

Mistakenly used opposite of intended Mistaken for mg milligram Can be misinterpreted for another medication Misread at U units

Write out greater than and less than Spell out microgram

Ug (**) Any drug name abbreviations

HCI, AZT, DPT, HCTZ, MTX

Spell out the intended medication

Cc

Cubic centimeter =

Write mL

(**) IU (*) MS, MS04, MgS04 (*) q.d, QD, QOD (*) ss

mL International Unit Mistaken for IV or the number 10 The two are mistaken for each other Write International Unit Write Morphine Sulfate or Magnesium Sulfate Write Daily or Every other day Write sliding scale

Morphine Sulfate or Magnesium Sulfate

Every day or Every other day Sliding Scale

The two are mistaken for each other Mistaken for the number 55 Mistaken for SL (Sublingual) Mistaken for three times a day

Subq or SC (**) T.I.W. or t.i.w.

Subcutaneous

Write subcutaneous

Three times a week

Write three times a week suggest writing actual days Write Units

U or u (*) Zero after decimal point (1.0mg) (*) Zero not placed in front of decimal (.5mg) (*)

Unit

Mistaken for a zero or a 4 ex. 4U seen as 40 Mistaken for 10mg if decimal is not seen

1 mg

Do not use terminal zeros after whole numbers Always use zero before a decimal when the dose is less then a whole unit

.5mg = 0.5mg

Mistaken for 5mg if decimal is not seen

(*) Is a JCAHO minimal requirement Do Not Use abbreviation list (**) Is an expansion option of the JCAHO Do Not Use abbreviation list No (*) is a suggested Do Not Use abbreviation