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CYA: Charting

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1 Does anyone know of a good book on proper charting? What to chart, how much, when. How late can you do a late entry chart note? Ect. Some patients you have to CYA and you feel like you really need to chart extra well. Some nurses tell me to document everything in detail and others say that you can hang yourself on too much charting. Any books or even suggestions from experienced nurses; particularly in OB, is great appreciated.
I don't have a book to offer but I can say that I have ALWAYS charted to CYA.That sweet old man and his family treat you well now but if he falls out of bed on your shift and has a brain bleed from hitting his head you'd better chart all the times you tried to get assistance from the MD and were waiting for a sitter to be at his bedside or the family left the room, etc., etc.I always wanted to be able to paint a clear picture for myself if I ever HAD to defend my actions and nursing judgment in the future.

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Buy the book "Chart Smart"

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Alternatively, attend a seminar, by a nurse lawyer, on charting. It's an eye opener and money and time well spent.

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Quote from OtessaI don't have a book to offer but I can say that I have ALWAYS charted to CYA.That sweet old man and his family treat you well now but if he falls out of bed on your shift and has a brain bleed from hitting his head you'd better chart all the times you tried to get assistance from the MD and were waiting for a sitter to be at his bedside or the family left the room, etc., etc.I always wanted to be able to paint a clear picture for myself if I ever HAD to defend my actions and nursing judgment in the future.
Author: alice  3-06-2015, 16:47   Views: 708   
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