Legal implications of free-text charting

I have started a new job in a new hospital and of course there are differences in policies, but one that I'm particularly concerned about is free-text charting. In my previous job, we were instructed to keep free-text charting to a minimum as what you write can be taken the wrong way (in court). We generally would write notes, but they would be very vague and they were really intended to just chart that you did indeed do a rounding with the patient.

In my new job, the nurses do a free-text note that is intended to give the oncoming shift a rundown of what has been going on with the patient in general, and specifically during your shift. I agree that communication is extremely important, but I feel uncomfortable ENTERING this communication into the patient's permanent chart. It seems to me that free texting about medications I gave, descriptions of wounds etc. is double charting since I've already carefully documented my assessment in the chart. Also, there doesn't seem to be a standard for this, everyone does it very differently and it's not even mandatory. A few nurses say they refuse to enter these notes because of the legal implications.

Any thoughts on this? I'm a little confused and not sure what to think.

Thanks!
What do u mean by free text charting? I haven't heard this term. Is it like a running sheet that night staff use sometimes, ie: when everyone has done their main notes, if anything changes it is put on a running sheet.Is that what ur getting at?

No, this is asking for trouble and goes against their reasoning for free-charting. Have never come across this, but it sounds like the shift to shift report. Not for the chart. You chart your regular nursing charting in the chart. The 'free for all' that you give to the oncoming nurse stays between you and the oncoming nurse. We objected when they told us we had to have the CNAs present for shift report because then we had to censor what we said for the CNAs ears. I just don't see this as being appropriate unless it is done thoroughly and "chart" appropriate.

I believe free-text charting definitely has a place, and do it all the time in ICU/ER for CYA purposes.I would not write notes under the circumstances you describe. Report to so-and-so, all information communicated to oncoming nurse, questions answered. Done.

It's literally opening up a word document and typing away. It's not necessarily a SOAP note or SBAR etc., it's just whatever you want to say. Like I said, communication is vital, but it makes me uncomfortable that my communication to the next shift is on paper and ends up in the patient's permanent chart. In addition to this, we do a hand-written note that is given to the next shift that essentially would be the same information. (And of course, we do a complete head-to-toe assessment on a flowsheet in the chart).

She means you are writing in your own words rather than charting with drop-down or checkbox selections. Other people call it narrative charting.You don't need to be a lawyer to chart narratively; you just need to learn to write objectively. Doctors, social workers, and many other healthcare roles do it all the time. Why are acute care bedside nurses so afraid of it? (I think it's because they aren't sure how to do it.) Drop-down and checkbox charting is so limited that it doesn't always give a clear picture of the patient. After all, your assessment and intervention charting is being driven by the creators of the software or the form. If they didn't make a checkbox or dropdown that matches your assessment or intervention, what do you do then?

Quote from EmmieRNIt's literally opening up a word document and typing away. It's not necessarily a SOAP note or SBAR etc., it's just whatever you want to say. Like I said, communication is vital, but it makes me uncomfortable that my communication to the next shift is on paper and ends up in the patient's permanent chart. In addition to this, we do a hand-written note that is given to the next shift that essentially would be the same information. (And of course, we do a complete head-to-toe assessment on a flowsheet in the chart).

Quote from caliotter3No, this is asking for trouble and goes against their reasoning for free-charting. Have never come across this, but it sounds like the shift to shift report. Not for the chart. You chart your regular nursing charting in the chart. The 'free for all' that you give to the oncoming nurse stays between you and the oncoming nurse. We objected when they told us we had to have the CNAs present for shift report because then we had to censor what we said for the CNAs ears. I just don't see this as being appropriate unless it is done thoroughly and "chart" appropriate.

Sorry about all my replies. I now know what the OP is saying. You're talking about a shift-to-shift report being part of the permanent chart?If management insists, maybe you can all come up with a standard format that gets completed, and then any other less-than-savory information passed (he's needy...and I set limits on him by blah, blah, blah) can be verbal?

Free-text charting is not by itself more legally dangerous than drop-down charting. You can get yourself into trouble if you don't follow some basic rules when free-texting, but drop-down charting can also leave you in legal trouble if it results in charting that is too vague or less-than-accurate. Where I work, we chart our systems assessments using drop-down options, but then augment that with a written note that is much more patient specific and does a much better job of communicated the patient's assessment, plan, progress, etc, which is the goal of charting, use in court is secondary. This note is essentially a shift-to-shift report than can be accessed by other caregivers and at other times.The only advantage to drop-down charting, and why it's used so often, is that it facilitates data mining, which can't be done with free-texting.What EMR are you using?

Quote from EmmieRNI have started a new job in a new hospital and of course there are differences in policies, but one that I'm particularly concerned about is free-text charting. In my previous job, we were instructed to keep free-text charting to a minimum as what you write can be taken the wrong way (in court). We generally would write notes, but they would be very vague and they were really intended to just chart that you did indeed do a rounding with the patient.In my new job, the nurses do a free-text note that is intended to give the oncoming shift a rundown of what has been going on with the patient in general, and specifically during your shift. I agree that communication is extremely important, but I feel uncomfortable ENTERING this communication into the patient's permanent chart. It seems to me that free texting about medications I gave, descriptions of wounds etc. is double charting since I've already carefully documented my assessment in the chart. Also, there doesn't seem to be a standard for this, everyone does it very differently and it's not even mandatory. A few nurses say they refuse to enter these notes because of the legal implications.Any thoughts on this? I'm a little confused and not sure what to think.Thanks!

Quote from dudette10She means you are writing in your own words rather than charting with drop-down or checkbox selections. Other people call it narrative charting.You don't need to be a lawyer to chart narratively; you just need to learn to write objectively. Doctors, social workers, and many other healthcare roles do it all the time. Why are acute care bedside nurses so afraid of it? (I think it's because they aren't sure how to do it.) Drop-down and checkbox charting is so limited that it doesn't always give a clear picture of the patient. After all, your assessment and intervention charting is being driven by the creators of the software or the form. If they didn't make a checkbox or dropdown that matches your assessment or intervention, what do you do then?

Dudette, I find that our charting system allows for sufficient detail to describe the patient in detail. It also allows for addition of words that are not in a drop down list. (I should maybe add that all of our charting is computerized)Here is an example of what I'm talking about. This is what I might find in a note:"Alert and oriented. Medicated for pain twice. Heparin drip infusing. Dressing to abdomen clean, dry and intact. Bowel movement x1".My problem with this is...I've ALREADY charted all of this. If I use the wrong wording, but this is as much a part of the legal document as my head-to-toe flowsheet (which is not just a one-time flowsheet, it allows for documentation of any changes such as charting pain med effectiveness, bowel movements, dressing changes, and implementation of new orders, etc.), then does my head-to-toe flowsheet credibility come into question if it contradicts my note? Like if I have a blood sugar entered into the chart in real time, and then I write in the note that I gave d50, but accidentally cite the time as 5 minutes prior to the actual blood sugar check, for example. Not sure if this is a good example, but hopefully gives you a better idea of what I'm concerned about here.