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Source:

Nursing2015

February 2005, Volume 35 Number 2 , p 27 - 27

Author

  • ANNE HALLIDAY RN, CPAN, BSN

Abstract

Graphics

  • Figure. No caption a...

    COMPLETE, TIMELY CHARTING can save you headaches in nursing care and protect you if a malpractice lawsuit is filed. Carefully noting the timing of key changes in your patient's condition helps create a time line that can be used in your defense to show that caregivers responded promptly and appropriately to a crisis.

    Suppose you're caring for a patient who develops bleeding problems after surgery. A note that simply states that the patient returned to the OR because he was bleeding would be inadequate. Complete documentation includes the time bleeding was noted, the time the patient's surgeon was notified, the time she arrived to assess the patient, and the time the patient returned to the OR. For example:

    Figure. No caption available. In this example, events are documented clearly and in the proper sequence. Follow these tips to make sure all your charting meets this standard:

    * No matter how ...

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