Defensive charting
Long our lifeline, charting can
also be our demise nowadays. "If
it's not charted, it wasn't done"
still holds true, but now we have
to avoid electronic documenta-
tion's double-barreled dangers:
"Charted, but not done" and "Not
charted, not done." Remember,
the medical record is the most
important piece of evidence in a
malpractice lawsuit, forming the
basis for both the allegations and
the defense. Many law firms are
hiring experts in EHR technology.
These experts know how data is
generated, how it is reported and
how it can be of value to the
plaintiff or defense. Practice
defensive charting. Check what
your documentation says, and
review the entry before finalizing
it. One chart at a time.
OSM
Dr. Cyriax
(clairecyriax@yahoo.com) is the
nursing educator at Center for
Ambulatory Surgery, Hackensack
(N.J.) University Medical Center
(part of Hackensack Meridian
Network).
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