Proper charting can lead to a high standard of patient care and may reduce liability risks for the medical team. These records document everything related to the patient, including their history, treatment plans and progress. The information can be used to support clinical decisions.
Medical professionals must consider several things when charting. Each can have a direct impact on the patient’s care and the professional’s liability when complaints are made.
Timely and accurate charting is important
Structured charting processes, such as forbidding medical professionals from using copy-and-paste and prioritizing timely documentation, are beneficial. Checklists, standardized templates, and multiple levels of review may also help ensure chart accuracy.
Everything related to patient care must be fully documented. Any incomplete or inconsistent entries can cause problems with the standard of care the patient receives. All information that’s put into the chart, including vital signs, symptoms, test results, medications and other treatments must be accurate. Failure to update treatment plans, illegible handwriting and incorrect dates must also be avoided.
When errors are made during the charting process, they must be corrected in the proper manner. Nothing in a chart can be erased or deleted. Instead, the correction must be stated with a date and initials to denote when the correction was made and by whom.
Any medical professional who’s being accused of negligence or malpractice may find that charting can play a pivotal role in the case. This is why it’s crucial that charting is always handled properly and professionally. Working with someone familiar with proper charting may be beneficial in these situations.