By defensive charting, we mean protective. Who are you protecting? With proper documentation, you protect your patient and yourself. Chart only what you see, hear, feel, measure, count, and experience; not what you suppose, infer, or assume. Chart as if the words you write reflect the actual and complete record of the care rendered, because they must. Chart as if every word could one day be scrutinized in a court of law, because it can.

Be familiar with institutional requirements and clinical protocols (i.e., “assess and document every hour a patient is on restraints”). However, keep in mind that there seldom are concrete “rules” about how long, how often, or what exactly you should chart. Remember, nursing is a science, thus the importance of clinical skills, but nursing is also an art, and like any art, your charting will develop and improve with practice. Here are some key words to help you review and evaluate your charting.

Ask yourself, is my charting:

• Chronological
• Comprehensive
• Complete
• Concise
• Descriptive
• Factual
• Legally aware
• Legible
• Objective
• Relevant
• Specific: uses exact measures such as “3 cm”
• Standard and consistent with abbreviation and symbol usage
• Thorough
• Timely

Mastering the lingo of a nursing assessment is often challenging, too. “What exactly do I write?” is a common concern. A natural response would be to look for a quick and standard answer to “fill in the blank.” However, it is a dangerous practice to think that there is a recipe answer to “what to write” when assessing a particular area (i.e., for breath sounds: “breath sounds clear over all four quadrants”).Your charting should reflect the objective truth of your experience and observations with that patient.

The point is there is no “automatic” way to chart. Although routines will develop in clinical practice and common occurrences begin to emerge, approach each patient encounter with the uniqueness that it deserves and do not presuppose an outcome. Remember: write what you see, hear, feel, measure, count, and experience.

Source: This excerpt is adapted from Quick-E: Charting, a part of the Quick-E series. The 12 new editions, with a revamped look and updated information, will roll off the presses next month.