Medical records are paradoxical. While despised for their necessity and consumption of valuable time, they are cherished for their usefulness. They are the most reliable indicator of what did or did not happen during any given shift. Legally, the medical record can be your best friend or your worst enemy. In the courtroom, they are the witnesses whose memories never fade. Here are a few tips on how to construct effective documentation.

Thorough is the name of the game. Malpractice attorneys are just as good at seeing what is missing as they are at scrutinizing what is there. As a common litigation tactic, the plaintiff’s attorney will attempt to “commit” the nurse to the record, seeking to establish the record as a full and complete chronology of the patient’s care and treatment. Once the nurse agrees the record is complete, the attorney can then argue that if the event was not documented in the chart, it did not happen. The medical record should be inclusive of all objective information.

The consequences of illegible handwriting can be costly. Any entry in the medical record should be clear and legible. An illegible entry can be subject to a number of different interpretations and could misrepresent the care given to the patient. Further, if you can’t read the entry yourself, your credibility with the jury will be severely damaged. For example, to avoid making the record appear as if it has been altered, never leave blank spaces or “squeeze” words into a line. If you spill your lunch or a cup of coffee on the record, don’t discard the original. Rewrite it and put both pages on the chart. Use ink. Never use white-out. In other words, use common sense: if your writing is sloppy, your care giving skills may be perceived that way, too.

Don’t wait until the end of the shift when the facts are no longer fresh or are blurred by facts about other patients. Also you may be tired or rushed at the end of the shift and this can lead to recording errors. Note the time of the entry and don’t allow big gaps in time frames. Assess frequently and consistently. Continuity is key. If you chart “patient was found on the floor again,” a previous entry should support that statement.

Record only what you see, hear, smell, feel, measure, and count. Don’t assume or infer. For example, if a patient pulled out his nasal oxygen and removed his abdominal dressing but you didn’t observe him doing so, write, “patient was found sitting in bed, nasal oxygen cannula lying on pillow, O2 running at 3L, abdominal dressing found on the floor, patient gown had approximately 50cc of dried blood in the area covering the surgical site.” If the patient says he pulled out the O2 and took off his dressing, record it as a direct quote. Patient states, “I took that thing out of my nose…”.

Avoid using colorful phrases and terms that could be considered insulting by the patient. Do not use “FLK” for “funny looking kid” or “SOB” for “shortness of breath”. Using inappropriate language or comments is unprofessional and would appear to a jury that the care was unprofessional and demeaning to the patient. Avoid language that suggests a negative attitude toward the patient, such as obstinate, obnoxious, drunk, bizarre, or abusive. The patient has a legal right to see his medical record. If he sees a derogatory reference, he’ll be angry and more likely to sue. The off-hand comment of a nurse can trigger a lawsuit or contribute to a patient’s loss of confidence in the care he is receiving.

The various purposes of documentation in the medical record are best met with complete, clear and concise charting. The nurse becomes the storyteller, a neutral, unbiased caregiver who can objectively describe the care given to a specific patient. In doing so, a record is created that substantiates the professional knowledge, common sense and compliance of the nurse in providing that care.