If It Wasn’t Charted, It Wasn’t Done (Say Whaaaat?!?)

One of the most blatantly wrong things I repeatedly hear in nursing, a phrase that I first heard when I was in nursing school is the saying “if it wasn’t charted, it wasn’t done.”  At one of the AWHONN conventions I attended, I went to a legal issues in nursing session and took away a very valuable message—We do a hundred things a day that we don’t think to chart, don’t have time to chart, or just forget to chart.  That doesn’t mean we didn’t do it. It means we didn’t chart it.

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I have not been to court (yet!).  But we all know most of us will one day find ourselves there. Working in labor and delivery, it’s hard to escape your career without finding your way in some sort of legal issue. I am sure my time will eventually come.  If you were called to court, how confident would you feel?  If they blow up your charting, how confident would you feel in your practice?  First of all, every maternal-newborn nurse should be a member of their professional organization, AWHONN.  Consider this evidence that you are vested in your profession and committed to providing my patients with the best possible outcomes.  If anyone were to try to intimidate me, this would be one of the first things I would tell them.

At that AWHONN convention, in that legal issues for nursing session, one of the most important things I took away were these words: I know I did it, because it’s part of my daily professional practice.  So how do I know I did it if it wasn’t charted?  Well, I know I did it because it’s part of my daily professional practice 😃  How do I know I repositioned that patient when she was having variable decelerations?  I know I did, because that’s part of my daily professional practice. If anyone were having variable decelerations, I would immediately reposition the patient, because I know that variable decelerations are a result of cord compression.  That is part of my daily professional practice.

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How I feel when I try to advocate for a patient.

I thought that those words may have been one of the most important things I’d ever heard about OB. I don’t think I’m an expert in anything.  And I in no way think I know everything. But I feel like we should all help each other, spread any useful information we come across, and support each other as colleagues and as women, because we’re all on the same road.  Our paths may look different, but we’re all on the same journey.  So chart defensively. Try to remember to chart what you do.  Try to remember to chart everything you do that pertains to maternal comfort (it’s not just all about the meds you give and when the physician is at the bedside).  I always thought that it would be hard to make me look like a bad nurse if I’m constantly talking about everything I’m doing to try to make the patient more comfortable (and I do want her to be more comfortable.) Chart when you’re in the room.  And if you ever find yourself in a courtroom, or talking to a lawyer, I hope that you have done everything you can in regards to your own professional development so that no one will ever be able to call into question your professional practice.  ❤

 

 

Until my next delivery! ❤

 

 

 

 

Until my next delivery ❤


14 thoughts on “If It Wasn’t Charted, It Wasn’t Done (Say Whaaaat?!?)

  • April 29, 2014 at 6:00 am
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    How difficult when taking care of patients and not having time to chart…happens too many times,..we carry the brunt, no matter what

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  • April 29, 2014 at 6:31 am
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    Thank you so much for sharing your knowledge with us. I can’t remember how many times I heard that saying in the last 10 years. I’m a big believer in first and foremost caring for my patient and trying to stay caught up on my charting. The biggest thing for me is to not sacrifice the “caring” part of nursing to make sure I wrote down or typed everything I did rather than doing it. I worked with one nurse whom was always soooo good at staying up on her labor charting, even while her patient was pushing. I never could figure out how she was so good at documenting so thoroughly, not having to catch up after the delivery. I assisted during one of her deliveries and I realized how she did this. She sat at the monitor documenting while the patient pushed, without any assistance from the nurse. This made me so sad. Not to say that nurses can’t do both well but I tend to focus solely on helping my patient get their special miracle out safely. There were times I had to catch up on my flow sheet after delivery (thank God for strip charting) but I always felt good about the care I gave. I’ve worked at a couple of facilities that actually discourage paper charting or strip charting. How do you hold a leg and a hand and 4×4’s and type into the computer every step of the way. I think technology is a wonderful thing and can help with patient safety but can also pull a nurses attention away from the big picture. Sorry for the rambling, it’s just so nice to hear good advice from someone who lives it. Thank you so much.

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  • April 29, 2014 at 11:54 am
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    As you said, its SO important to keep up current with your professional practice by joining professional organizations and becoming certified in your specialty area! That’s one of the first things asked when you give a deposition. And I also know far too many nurses who have excellent charting, but little interaction with the patient. I think part of that has come from so many of our patients having epidurals. Bring em in, epiduralize ’em, and pit ’em. Patient takes a nice nap til she’s complete, and plenty of time for sitting around charting (often). As some one who has been a labor nurse since the good old days pre-epidural, we learned to chart on the fly while patients labored with no medication…you HAD to be in the patient’s room and they required intensive labor support! (sigh…I miss those days, truly!)

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  • April 29, 2014 at 1:24 pm
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    Are we so unprofessional that it is assumed that if it wasn’t charted it wasn’t done? Maybe we need to go to tablets that voice record, so we can voice-chart and it types it for us! That way we can be at the patients bedside providing the best nursing care and not worrying about getting into legal trouble or nasty-grams from the chart-audit peeps.

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    • April 29, 2014 at 1:33 pm
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      Lol. I actually saw an ortho that did that!! It blew my mind…but of course, he had so much trouble using it he kept calling his nurse to fix it!

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    • April 30, 2014 at 3:34 am
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      That term comes from the legal profession. Any nurse knows that it is a flawed statement but when you are in court you are in their territory.

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  • April 29, 2014 at 9:12 pm
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    I am an OB/GYN 23 years out of residency. Long time. I have never been sued primarily but I have been named (and dropped) in suits against my partners. One time I was deposed and did exactly what you said: I answered that I always do this step and that I do not need to chart it because I always do it. I also do not chart exclusions, just pertinent positives. I still came out beaten, bruised and feeling like an idiot. The plaintiff’s attorney was pure evil. You know in your heart that you did the right thing but I still get sick to my stomach thinking about that deposition.

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    • April 29, 2014 at 9:17 pm
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      I’m thankful you do what you do! My next post is about great physicians…It’s fun to talk about the crazy ones, but the truth about the good ones is that they do it because they love it. But good or bad, everyone seems to eventually find themselves deposed. Thank you for your comment. xx

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    • May 5, 2014 at 11:44 am
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      Same here; only deposed once in my 25 year career, and it was traumatizing! It may have factored into my decision to transition from the bedside to teaching.

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  • May 21, 2014 at 2:33 am
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    Naive if you think that saying that is part of my professional practice will save you on the stand. Nor will being a part of your professional organizations. Good for you for keeping up to date in your profession and having high standards but as a RN who has been deposed and seen many trials your best defense is good solid charting. I am a nurse attorney and I defend nurses! I am proud to be a nurse and I spend many hours teaching young nurses the ins and outs of the legal world

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    • May 21, 2014 at 2:43 am
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      I totally agree that solid charting is critical. But I disagree with the comment that if it wasn’t charted, it wasn’t done. I hope I’m never on the stand. We have a joke in our family…My husband thinks he’s the nurse and I think I’m the lawyer. Lol one day… ;)

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  • July 31, 2014 at 4:11 am
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    You inspire me to keep doing the job after 20 plus years. Thank you! Bless you and your family.

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    • July 31, 2014 at 4:24 am
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      <3 reading the comments people post on my blog is so rewarding. And it confirms what I already believed…that 99% of kind and the other 1% I don't care about. lol j/k xx

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