By defensive charting, we mean protective. Who are you protecting? With proper documentation, you protect your patient and yourself. Chart only what you see, hear, feel, measure, count, and experience; not what you suppose, infer, or assume. Chart as if the words you write reflect the actual and complete record of the care rendered, because they must. Chart as if every word could one day be scrutinized in a court of law, because it can.
Be familiar with institutional requirements and clinical protocols (i.e., "assess and document every hour a patient is on restraints"). However, keep in mind that there seldom are concrete "rules" about how long, how often, or what exactly you should chart. Remember, nursing is a science, thus the importance of clinical skills, but nursing is also an art, and like any art, your charting will develop and improve with practice. Here are some key words to help you review and evaluate your charting.
Ask yourself, is my charting:
- Legally aware
- Specific: uses exact measures such as "3 cm"
- Standard and consistent with abbreviation and symbol usage
Editor's note: This excerpt is adapted from Quick-E: Charting, a part of the Quick-E series. For more information about HCPro's latest nursing resources, click here.