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What role do critical thinking skills play when charting?

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Critical writing is as important as critical thinking. Good documentation is a vital part of patient care and nurses need to be able to validate in the written medical record what they did or what they chose not to do. With all of today's risk management and legal concerns that challenge healthcare delivery systems, as well as the caregivers, it is vital to demonstrate steps and actions taken to support the patient.

Identifying a patient problem, potential consequences, and necessary actions are vital elements of critical thinking for nurses. However, without appropriate and timely documentation, there is no written record of what occurred.

Transforming critical thinking into the written format provides:

  • A legal record to support a nurse's:
    • Identification of a problem
    • Actions taken in response to the problem
    • Patient outcomes related to any intervention
    • Collaboration with other members of the healthcare team
    • Compliance with nursing standards of practice
  • A timetable of events to reference as a tool in determining ongoing care and needs of the patient
  • Validation of the nursing process that incorporation critical thinking

Remind nurses that charting mistakes can lead to allegations of negligence. These are the most common charting errors:

  1. Failure to document pertinent health or drug information
  2. Failure to record nursing actions
  3. Failure to record medications given
  4. Recording on the wrong chart
  5. Failure to document a discontinued medication
  6. Failure to document drug reactions/changes in patient's condition
  7. Improper transcriptions of orders or transcription of improper orders
  8. Writing illegible or incomplete records

—Shelley Cohen, RN, BS, CEN

(September 2009)