As a legal Nurse consultant who spends a lot of time reviewing medical records, I thought I would share a few tips. First of all, the records I review are electronic, they have been scanned into a record-based program. This does not mean that if a hospital doesn't have computer charting, that those records won't become electronic. Many of the pages I review are handwritten. This is a time consuming task!

If you didn't chart it, it wasn't done! That is a common rule of thumb that holds true always. As an RN, you probably monitor your patients well, and it's second nature to know when a particular patient needs closer watching due to their potential to deteriorate. When that patient does "crash" and possibly die, does the record reflect that you were monitoring their vital signs, color, and mental status for the time preceding the event? Or is there a routine assessment done with one set of vital signs and then three hours later, a code blue log. If this patient or his family sues for negligence,  the reviewer of the record will be looking for documentation that showed what led up to the event, what the nurse did to intervene, and whether it could have been prevented. Let's face it, it's the nurse, not the doctor who is at the bedside 99.8% of the time!

Make sure you are charting on the right patient! Most of us have computer based charting at the workplace and in order to chart a note, the cursor highlights a patient name and then a record opens where data is to be placed. Very often, you can be looking at a patient's name, but the cursor or highlight is on another patient. We have all done it and doctors do as well, as I have often brought discharge papers to a patient in the ED to find that the name is incorrect and they almost walked out with a prescription they couldn't use! The other side of that story is that another patient now has a discharge diagnosis that makes no sense. While most of us like the checklists, and notations via keyboard instead of handwritten notes and paper charting, the hazards are many.

Document your communications with physicians. Nurses are patient advocates and it is the nurse who will call the MD to get an order for more pain medicine, or to report deteriorating vital signs, or notify him or her of suspicious findings. Does the doctor call back right away? Were orders received and followed through?  In the ED, it is relatively easy since the physician is in the department, but notes should still reflect who was talked to, and if new orders were received. This includes not getting an order. When you tell a physician that the patient is having increased chest pain and he declines a response, if the patient arrests, your documentation could help you defend your actions if there happens to be a suit. A nurse who works on a floor and has to call a physician should document as well. How long was the response time? Were you ignored or did you get appropriate orders?

If you go back and add an entry because you didn't have time or you remembered something later, chart it as "late entry" with the date and time. With most computer charting, times can be altered electronically, but you want to make sure that your entries don't look suspicious or suggest tampering.

Get credit for all you do! Nurses routinely put up side rails, leave call lights, and monitor safety. Some records have a check-mark system to note that these things have been done. If not, write it yourself. If your patient falls out of bed and breaks a hip, can the family go to court and say the nurse left the side-rails down and a confused patient unattended? Of course medication administration is a big focus for hospitals. Medication errors injure millions of people and cost billions of dollars annually. Many hospitals have bar codes that must be scanned or other methods to confirm that you are administering to the correct patient. But do you have the correct pill? Is it the right time? And if you are giving Digoxin, did you note that the patient's heart rate is above 60? A nurse cannot double check enough when it comes to this critical role of dispensing medications.

Some No-No's:
Don't chart a symptom without noting what you did about it. If you write that the patient's nose began bleeding, does the chart reflect what you did? Who you notified? Did you give a dose of Plavix or Coumadin two hours later?

Do not alter a patient's record - in regards to a paper chart. Blacking out an entry or going back to change something after the fact is a criminal offense.

Don't use imprecise descriptions. "Patient in a lot of pain". Document that chest pain is 8/10. "The incision is wide open". Chart that the incision is 1.5 cm wide, 3 cm long and unapproximated.

Don't chart something you haven't done or something you plan to do. It may seem obvious, but you may not do something you plan to and charting care you haven't done is fraud.

Don't chart unaccepted abbreviations. Check with your institution, most have a list of accepted abbreviations. Our facility allows a nurse to chart "Patient is alert, NAD". This is known to most as "no apparent distress". On the other hand, our facility does not allow us to chart "Aspirin QD". We must write "daily". Abbreviations with medications are tricky because a wrong abbreviation when taking verbal orders can cause a patient to be administered medications incorrectly. Will that MD defend himself as having given a correct verbal order if he is taken to court? Absolutely, the nurse who wrote the order is on her own.

Charting is a part of every nurse's life and shouldn't be a cause for anxiety. It should be looked at as your proof that you have performed your duties well and as competently as the next nurse, if not more so. Leave at the end of a shift knowing that you have safeguarded your professional future and will be ready to start the process over tomorrow.