Nurses have many responsibilities when they’re taking care of patients. One of these is keeping each patient’s chart updated with several facts, such as the patient’s condition, care, response to treatment and current needs. Nurses often spend more time with patients than other members of the care team, so their charting can become a critical source of information for clinical decisions from doctors and therapists.
Accurate charting helps to show what a nurse observed, what actions were taken, when care points were provided and how a patient responded. Medical charts include records of the patient’s vital signs, medication administration, wound changes, patient education and pain levels. It can also note safety concerns, things that a nurse contacted any other provider about and what follow up steps are necessary. All of this information allows the next person reviewing the chart to have a complete picture of what’s going on with the patient.
Incomplete charts are a safety risk
Charts that don’t contain all necessary information can lead to patient harm because the next person reviewing someone’s chart won’t have all the necessary information. Incomplete charts can lead to missed care, duplicated treatments and misunderstandings about patient care.
Nursing documentation is a legal record
Nursing charts are a legal record that can be used if claims about substandard or negligent care are made. Poor documentation can lead to questions about the quality of care and if the patient received the necessary treatments.
Nurses should ensure that they’re providing patient care as ordered, and they should ensure that they handle charting in an accurate and timely manner. Failing to do this could lead to issues with a nurse’s license, which may require them to work with a legal professional who can help them to protect their license.
