icon Mneme

Documentation and Charting

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References:

  1. Nursing Review Guide, 1st Edition, ISBN 978-621-02-2289-0, by Glenn Reyes Luansing

Documentation, charting, or recording, is the act of placing patient and care information into writing for posterity. Any care not documented is not given, despite all testimonies. Patient charts are legal documents and can be used to vindicate or convict members of the healthcare team for inadequate, negligent, or otherwise non-standard care. Good documentation follows the following characteristics (mn. FLIP):

  1. Full, Factual, and Accurate: complete, empirical, and non-speculatory/circumstantial.
  2. Legible in handwriting, syntax, and grammar.
  3. Written Immediately after procedure. If late, the entry should be specified as an addendum.
  4. Personal/Confidential; documentation cannot be delegated to those who did not perform care. The act is personal to the nurse performing the care being documented.

Conversely, negative characteristics in documentation may be summarized by the following (mn. LISA):

  1. Language, Jargons, or Words that are unacceptable in medical records. Use formal, recognizable, objective language.
  2. Improper Corrections: crossing out, liquid taper, etc. are not allowed. Strikethrough: draw one or two straight lines across the mistake and write it as an error or mistake, then date the correction and sign.
  3. Spaces and skips: do not leave spaces to avoid tampering or addition of information. Obstruct empty spaces with lines.
  4. Abbreviations are only used when recognized by the medical community and medical terminologists.

Such documents are kept for five years after the discharge or death of the patient. The records are kept for the following reasons (mn. CLEARS):

  1. Communication for patient’s care between the members of the healthcare team.
  2. Legal document if necessary (if a case is medicolegal in nature, it is kept for life.)
  3. Evidence for insurance claims, decision-making of the nurse, investigations, professional liabilities, etc.
  4. Assurance of Continuous Care
  5. Research
  6. Statistics

Medical records are owned by the hospital and as such must be kept confidential against any unauthorized person, with its contents only being divulged with the consent of the patient’s consent or upon court order. Medical records are the best written evidence for medicolegal cases. A court order demanding the release of a document may be presented to the institution holding the record. This is known as a subpoena duces tecum.

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