"If it isn't charted then it didn't happen."
Whether you have been involved with health care for 50 years or 50 minutes, you have heard this expression. Plaintiff's lawyers love to ask about uncharted incidents during depositions and then use them to show the jury there was inadequate care at your facility.
We all know it is impossible to chart everything, every day, but when a lawsuit is filed, the chart will be the first item the plaintiff's counsel requests. Often times they will request the chart through a medical records request and then determine whether the chart is "flawed" enough to proceed with a lawsuit. Once the lawsuit is filed, the plaintiff's counsel will begin the process of finding "holes" throughout the chart. So, how do we overcome it? It all starts with making sure the caregivers know what, when and how to chart from the beginning. When charting, each caregiver should ask themselves three questions:
- What is the purpose of this entry?
- Have I communicated clearly to other team members?
- Does this documentation satisfy its intended purpose?
Not only should caregivers refer to the three questions above when charting, but they should also know the facility's documentation policies and procedures, including the correction of errors, late entries and writing new orders. The facility should have a plan in place to audit charts frequently, identify problems and come up with solutions. The caregivers should perform documentation in a timely fashion and accurately. For example, if quoting a family member or resident, the statement should be in quotations.
Charting has many purposes. Through charting, caregivers can inform the other shifts, Medical Director, Treating Physician and other providers of the condition of the resident. Charting ensures continuity and uniformity of care by enhancing communication. It helps support reimbursement and represents professional accountability. Charting may help protect the caregiver and the facility from liability. Finally and most importantly, charting helps caregivers give the best care possible. By using the tips above and keeping the purpose of charting in mind, your caregivers and facility can avoid a case of CHARTING GONE BAD!