You do countless things over the course of a case to ensure a successful outcome, but often don't think to include them in the patient's chart because, well, they seem like routine tasks. That's fine — until there's a problem. If complications occur or mistakes happen and your facility gets sued, clear and accurate charting could help you avoid legal trouble. Here are five ways to ensure documenting is always completed and done properly.
1Respect the process
You're constantly under the gun to complete cases, turn over the room and get the next case started. Completing the patient's chart might not seem like a priority, especially if the procedure was routine and you performed tasks you've done thousands of times before. But there's a reason why we chart. It's to tell the story about the reasonable care provided to the patient. While it might seem like the least important and most tedious task before you at the moment, it truly is your best weapon for defense against malpractice claims.
Juries believe that people will lie and embellish their stories to make themselves look better. They don't, however, question documents that were written at the time of the care before the lawsuit was filed. They view it as the real story you wrote down at a time when there was no reason for you to lie. It's best to always make note of your good work.
2Don't cut corners
Resist the urge to pre-chart, even if you know you'll be busy later, you know what the surgery is going to be like and you want to save a couple minutes by documenting ahead of time that something was done. This is a less hazardous practice with paper charts, because no one knows when notes are written, but every entry in electronic medical records is time-stamped. Don't put yourself in a position of having to explain to a jury how you noted at 7 a.m. that the patient came out of their surgery with no pressure injuries when in fact the procedure didn't begin until 7:15 am. Even if that aspect of the case doesn't have anything to do with why the patient is suing, inconsistencies in charting will put all the testimony from your side into question.
Whether it's cataract, arthroscopy or another procedure, there are things you know are going to happen during surgery. You can create a template that prepopulates standard aspects of patient care such as the position a patient will be in and what steps you took to prevent complications, such as putting a device on a leg to prevent thrombosis. That way, you only have to note or input a few variables, or correct changes that occurred to the routine flow of the case. Then, when you file the record, the time stamps will be coordinated to the end of the case.
Charts provide the opportunity to tell the story of the care you provided.
Templates, which are a great compromise between nurses who claim to not have enough time to chart and administrators who demand thorough documentation, should include the standard aspects of the case. This is similar to what individual surgeons do with established order sets. The orders are preset, and surgeons can deselect orders they don't want for individual patients. Do the same with your electronic forms. Creating preset elements for things such as patient positioning means you have to edit the form only when changes are made to routine care. Having preset elements in place helps at the end of procedures, when your focus shifts to preparing for the next case and you might miss completing aspects of the chart.
4Tell your story
Include a comment box in a template where you can note additional measures you took to make the patient comfortable and safe. For example, record that you provided padding for a patient with contractures or comforted a patient with autism. Juries are looking for reasonability and want to see that you cared about the patient's well-being. The extra things you did might not seem noteworthy to fellow surgical professionals, but could be what shows a jury that you really cared about the patient as a human being. Often, that can't be communicated by checked boxes on a form. You don't have to be verbose about the additional care you provided, by the way. In the case of the patient with the contractures, for example, simply note, "positioning pads applied." This phrase can support testimony that you acted to protect your patient.
5Understand the importance
Charting provides the opportunity to tell the story of the care you provided in the event of a legal dispute. It can also protect you and your organization from being liable for someone else's negligence. You might need to rely on your charting for back-up only occasionally, but when that need arises, it will provide crucial information that can tip the scales of justice in your favor. OSM