What to Chart When You Can’t Chart Everything: Practical Tips for Nursing Documentation

The variation in electronic health records leaves quite a bit of latitude for health care providers to document patient care. Some electronic health records provide many options to capture patient care, while others provide very few options, and both are inherently known for not capturing enough patient care necessary to demonstrate that a standard of care has been met.

An example of documentation that is frequently seen in medical records and is often presented as a problem in the courts has to do with skin breakdown. The prevention of skin breakdown fundamentally requires that patients who are not able to adjust their position are turned every two hours. According to the National Pressure Advisory Panel, many factors are taken into consideration when evaluating a tissue injury, but the first and primary intervention for all patients regardless of “other factors” is to turn patients. When a tissue injury develops (bed sore), stage II, stage III, stage IV, or suspected deep tissue injury, the scrutiny of care will include proving that the patient was, at a minimum, turned to even get close to meeting the standard of care for the prevention of wounds.

Nursing negligence may be alleged for failing to turn the patient every two hours. In addition, if the medical record does not show that the nursing plan of care includes an actual or potential problem addressing alteration in skin integrity it is assumed the turning patients was not done. If a wound develops, it is possible that a correlation can be made between the nurses’ failure to turn the patient led to and contributed to the skin breakdown.

When the medical record clearly demonstrates the patient was turned every two hours and still developed advancing staged wounds, then “other physical factors” are considered as significantly contributory. If the other physical factors do not exist then the documentation may be considered falsified charting. Other physical factors include, but are not limited to: lab results, diabetes, coronary artery disease, previous surgeries, age, infection, etc.

Examples of when care has not been documented and caused additional scrutiny of care are the following:

• Head of bed elevated. Elevation recorded with specific degrees is important when care involves aspiration precautions, limiting sheer, or hemodynamic measurements.

• Response to titration of medications in a critical care area. Titration of medication is expected to occur until a desired effect is attained particularly when orders are written in a protocol format. Medication management recorded in the medical record must reflect appropriate clinical judgment by the nurse.

• Fall prevention interventions. It is not enough to simply record or check off: fall prevention protocol in place. Should a patient fall on your shift, will the records show that what is listed in the protocol was done to prevent the fall? Be specific regarding interventions used when caring for patients determined to be at a higher risk for injury.

Medical record entries must be factual, accurate, complete, and timely. Use the FACT rule. It is very easy to remember.

FACTUAL means there must be enough detail of the facts that the story depicting the patient’s care is clear. Facts are clinical findings a nurse knows to be true. Facts may be lab results, clinical assessment, medications, vital signs, and it could also mean what the patient says. Put what a patient says in “quotations”. First-hand knowledge is another way to determine what should be charted. The best practice is to chart only that which is known to be true. An exception to this practice is during a crisis intervention when the situation utilizes a scribe as one might do during a code or a rapid response. The scribe charts as the events unfold and the documentation is reviewed for accuracy after the patient is stabilized by the health care team.

ACCURATE means the facts must be recorded correctly. The labs must be entered precisely if they are not crossed over through an electronic health record portal system. The movement of a decimal point just one place when recording a medication administered can convey that the dose administered was 10 times or even 100 times more than the dose ordered. Imagine if a record reflected that a nurse administered 10 mg of Atropine instead of 1 mg. How would this error be defended if a catastrophic result seems to be related to the medication error?

COMPLETE medical record entries are thorough entries. Don’t leave the reader guessing about patient care provided. Check the completeness of medical record entries by using: “O P Q R S T”.

“O” is for onset.

“P” is for precipitating or aggravating factors.

“Q” is for quality or quantity

“R” is for radiating

“S” is for situation

“T” is for time (time of day)

The final term, TIMELY. Medical record entries are expected to be written contemporaneously. All that means is charting as soon as possible after the event(s) occur. Timely in a high acuity setting is not the same as timely in a lower level of care, which includes long-term care settings. The higher the level of acuity; more entries are expected to be recorded regarding the patient care. A lower level of acuity will have fewer orders, fewer interventions, fewer interactions which equates to fewer entries representing the care rendered. The frequency of entries should be adjusted according to facility policies and level of patient acuity.