We Chart In Case We Get Sued

There are some good reasons for charting. Some computer systems allow us to bill as we chart. We also chart so you and others can monitor to see how the patient progresses over time. But, another, perhaps most important, reason for charting is for litigation purposes. Basically, you chart based on the 1% chance you might end up talking to a lawyer. 

So, let's say a patient dies in the ER. The family is a suing family. They love to sue. So, when their dad died, they sue. The nurse is named in the litigation. Pretty much anyone who's name the family new was named in the litigation. You were not named, for some reason. Maybe it was because you were in the room when the family wasn't. 

Either way, the hospital lawyer wants to see you. So, it's just you, the hospital lawyer, an assistant of some kind, and a stenographer. The stenographer is a lady. She says, "Okay, Mr. Lawyer is going to ask you some questions. We want you to state in a clear voice your answers. If you are asked yes or no questions, we want you to state clearly a yes or a no. Is that clear?"

You say, "Yes."

She says, "Great. That's exactly how to do it." She smiles. Then she clicks away at her stenographer machine. 

Then it's the lawyers turn to talk. He clues you in as to what has transpired up to this point. He says, so far, it has been determined that the nurses did a poor job of charting. 

According to their charting no sats were charted. The family claims the patient died because the nurses didn't monitor the patient closely enough. They didn't care. Because of their neglect the patient died; their dad died. 

So, that's where you come it. The hope is that something in your charting will prove that the patient was fine; that the patient was fine before he suddenly, unexpectedly went into cardiac arrest. The hope is that the patient died NOT due to healthcare related neglect. 

So, it's just you and the lawyer. You are in the hospital board room. It's a big room with a big table. You are sitting across from the hospital lawyer. The layer says, "Okay, before you is a copy of your charting. Can you read to me what is in your charting the last time you charted on the patient."

You read: "The patient's lung sounds were clear. The patient was in no respiratory distress. The patient was in semi fowlers and was pleasant. The patient noted no change with treatment." 

The lawyer said, "Can you read the vitals that you charted?"

You say, "The Spo2 ws 98% on room air. The heart rate was 80 and the respiratory rate was 20." 

The lawyer says, "What was the sat again?"

You say, "It was 98%." 

"Did you chart any other sats?" he asks. "Did you give any other treatments? Also, what was the sat you charted for each treatment." 

You say, "Yes. I gave 4 breathing treatments during the time the patient was in the ER. With each treatment the sat was 98% on room air." 

"At what times did you give the treatments?"

"I gave them at 12 a.m., 12:30 a.m., 12:45 a.m. and 1:15 a.m."

"So, the sat was 98% with each treatment." 

"Yes." 

"The patient was in no respiratory distress with each of these treatments, according to your charting that you have in front of you. Is that true?" 

"Yes." 

The lawyer says, "Great. T'hat's all we need!" He stands. He reaches across the table and offers to shake your hand. You shake his hand. He says, "If we need anything further we will give your boss a call." 

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The case never goes to court. The reason is because you charted so accurately. The nurses didn't chart any sats. Because you did in this made up case, you saved the hospital possibly millions of dollars. 

See, that's why we chart.