Chart to Save Your RN License: A Comprehensive Guide to What, When, and How to Document for Nurses

Book Synopsis: You can be an excellent nurse in the clinical setting and still fail to prove that you are an excellent nurse if your documentation is inadequate. Having worked in a variety of inpatient and outpatient settings, I understand the obstacles nurses face. There’s just not time, nor do nurses have the mental energy to meticulously document every little thing on top of the rest of their to-do list. That’s part of why I became passionate about documentation education. It doesn’t have to be an overwhelming, endless challenge to chart exhaustively in hopes that you enter enough data into the chart to defend yourself one day. Rather, leveraging the most critical data, knowing how to format notes and exactly what to say, and when to spend five minutes dumping information into the chart can be learned skills that make documentation faster, easier, and less stressful, while doing a better job of defending your actions.

The Importance of Documentation & Overcoming Obstacles
Purpose(s) of Documentation
Defensive Charting
Obstacles Impacting Quality of Medical Record
Overcoming Obstacles
Legal Responsibilities of the Nurse
Duties of the Nurse
Nurse Practice Acts
Duties of the Hospital
Hospital Policy vs. State Board of Nursing Regulations
Reasonable Prudence
Failure to Fulfill (Document) Responsibilities
Fulfilling Responsibilities vs. Documenting Responsibilities
What if Responsibilities Aren’t Fulfilled?
Mistakes Happen
Professional Liability Insurance
Malpractice
Medical Negligence
Acting with Malice
Fraud
What Happens When a Nurse is Charged with Malpractice?
What to Do if You Receive Notification of a Claim
Common Charting Mistakes & How to Avoid Them
The Most Common Errors
Charting By Exception & Charting to Capture Minimal Data
“But I’ve Always Charted This Way, and Nothing Bad Has Happened Yet…”
What You Should Be Charting
How and What to Chart
Quick Glance Charting Checklists
What is a Timely Manner?
Documenting Assessments
Sample Focused Assessment Criteria
Sharing the Responsibility
Modifying Electronic Data
Abbreviations
Standing Orders
Early Warning Systems Scores & Scales
Informed Consent
Special Circumstances
Paper Charting
Writing an Incident Report
Patient Leaving AMA
Patient Threatening to Sue You
Identifying Patient Belongings
Another Member of the Team is Not Documenting Correctly
Restraints
Defective Equipment
Suspected Abuse
Patient Requesting to View Their EMR on Hospital Computer
Narrative Notes
When & How to Write Notes
One Note or Several Notes?
Daily Narrative Notes
Examples of Common Notes Written As-Needed
How to Title Narrative Notes
How to Format Notes
Using Patient Names in Notes
Length of Notes
Create a Template
Tips for Less Stress When Charting
BONUS: How I Chart on a “Typical” Shift
ABOUT THE AUTHOR:
I'm Andrea, RN-MSN. Perfecting my own documentation and working to find concrete guidelines to share with my fellow nurses has become my passion. As I gained more knowledge and researched the dusty, forgotten corners of the internet for obscure evidence-based practice and case studies, becoming a subject matter expert on nursing documentation lit a spark because sharing this information helps empower nurses to understand exactly what should appear in their patient charts, where, when it should entered, and how it should be phrased.