Accurate documentation by nurses is an essential part of providing care. Errors documented in medical records can be used by licensing Boards and attorneys to assess or prove negligence in the care provided to patients. Precise and thorough documentation is a key factor in proving that proper care was given to a patient by the nurse. Here are 5 tips to assure you are charting correctly:
- Do not chart care that was not given
- Avoid writing in the margins
- Chart as soon as possible after care is given.
- Only use abbreviations that are generally accepted within the industry
- Simply chart the facts. Do not include personal estimations of the care given or needed.
Every nurse is best served by keeping simple, legible and accurate charts. This will help you avoid discipline from your licensing Board in addition to protecting yourself from possible litigation.