8 Most Common Charting Mistakes in Psychiatric Nursing

When writing any kind of chart note, anything that’s narrative in nature, you have to think how it will sound being read out loud in a court of law during a jury trial. 

• Will your narrative sound objective? 

• Will it show a methodical approach to patient issues? 

• Will it capture all of the work you did on behalf of the patient, all of the interventions, large and small, that you offered? 

• Will it paint a picture of you being a competent, knowledgeable collaborator and patient advocate?

If not, then your documentation will work against you in a lawsuit…and against the patient during their hospitalization!

How will this topic show up on your exam?  Well, if it does show up, it’s likely to be in the form of a scenario--probably a seclusion or restraint episode--where you’re given the choice of four chart notes, three of which have serious problems with them.  Let’s briefly go over the kinds of documentation problems that psychiatric nursing is particularly prone to.

1.      Emotionality.  There is no room in a chart note for the nurse’s emotions.  None.  Ever.  Period.  These chart notes need to objectively report what happened or how the patient is doing without subjective commentary.  Here’s an example of what I mean:

“At 2210, heard shouting coming from patient’s room.  Quickly responded along with Tech and found patient standing on bed naked quite agitated.  When patient saw us, patient became louder and shouted, “You bitches are going to die.  We’re all gonna die.  The kingdom is coming and we didn’t make the cut.  Do you understand me?  There’s nothing the world can do.  Get out of here before I use my death rays on you.” 

I’ve seen some chart notes that added things like, “I found the patient’s remarks disrespectful and insulting” and  “I told the patient to calm down, that I wouldn’t respond to his calling me names.”  No, no, no.  How a patient’s behavior (which we must always keep in mind are SYMPTOMS of his illness and never, ever personal towards us) affects us is something we have to work out with a colleague, supervisor or therapist, but it does not get reported, or even alluded to, in a patient’s chart.  Our notes must convey levelheadedness and professional but compassionate detachment.  Hostility towards the patient will have the jury awarding the patient a fat settlement and strip you of your license. 

2.      A lack of follow-through:  A psych unit can sometimes feel pretty chaotic, making it easy to get distracted.  But one of the best ways to demonstrate true competence and patient-centered care is documenting all the follow-through you do on behalf of the patient. 

For instance, a patient’s family member calls, saying they’re concerned their loved one, who is allergic to milk, is still getting dairy products for snacks or on their tray.  Documenting the conversation with the family is awesome…but then documenting later what the outcomes were of your conversations with the kitchen and the patient, shows you to be a nurse who advocates and protects their patients.  Every time you call a provider about anything on the patient’s behalf—a lab value, a question, a concern—make sure you document that call.  There’s no telling how critically important that documentation may be later in the day…or later in the decade, if someone decides to sue.

3.     Vagueness.  Being vague is basically a waste of chart space.  To say, “The patient offered no complaints” tells the reader zero…expect perhaps that there is a lack of investment in this patient’s wellbeing, which you definitely do not want to convey to anyone. 

This is the time to tell it all.  Use your detective skills.  Report how the patient walked, what their tone of voice is like when they speak to the clinical staff, what their personal hygiene is like.  Use details:  “Patient’s nails appear jagged and have dirt under them.  Patient’s feet are covered in dirt and right heel has two 0.5” long scabbed over cuts, which patient states do not hurt when they walk.”  That’s detail that tells us all kinds of things about the patient’s current state.  We can visualize this patient and the condition they are in at the time of this writing. 

That’s what you want—a visual picture of the patient that’s as clear as a photo. 

4.     Reporting topics patient discusses vs quoting patient directly:  When a patient tells you something or says something that others should know about, just reporting that “the patient made some angry statements” does not give the reader (or the jury) a feel for what really happened.  Instead, use quotes.  No matter what the patient states, how vile it is or how offensive, quote the patient exactly, just as I did in the example before.  As your colleagues read your note, they’ll be much better informed as to what happened, helping them to be prepared for what might happen next. 

Saying simply that the "patient lost control" vs showing how they lost control through their own words and behaviors tell two very difference stories.  There’s nothing more convincing to a jury (or CMS, the State, or Joint Commission) that a patient really had lost control of their behavior and thinking than capturing verbatim what a patient said and did during their crisis. 

5.     Blaming others:  If something happened (or didn’t happen) because of someone else’s mistake or negligence, put all of that in an incident report or an email to your supervisor.  But do not put it in the patient’s chart, and do not allude to there being an incident report or email on the situation, because once referred to in a court document, it too becomes a court document, and you don’t want that.  Again, charting must be patient-centered, not nurse- or hospital-centered.

6.     Forgetting to document all the small things:  I say small, but you and I both know that it’s the small stuff that makes all the difference in patient care.  Sitting with the patient for 15 minutes using your therapeutic communication skills, and then including comments on how the patient responded to your intervention,  shows investment in the patient as a person and diligence as a nurse.  Capturing all the patient education you do for each patient is critical, too. 

If four hours after building a nice rapport with a patient,  that same patient takes a swing at you, in the context of the earlier interaction this demonstrates clearly how ill the patient really is and that your behavior is unlikely to be the reason for the patient’s loss of control. 

Don’t see your documentation of these small moments with patients as “taking credit.”  See it as a running commentary of how the patient is or is not progressing.

7.     Documenting much later:  Be timely.  Your documentation will be so much more believable, not to mention accurate, if you chart as you go through your day vs doing a core dump at the end of your shift in a state of exhaustion.

8.     Not making sense:  This one won’t show up on the exam, but just as a suggestion, make sure for your own practice you re-read what you’ve just written before you make it an official entry…that can never be changed.  Typos and missed words can garble and change the meaning of a sentence in dramatic ways—ways that could present serious problems down the road.  Live by the rule, “Read Before You Send.”  Make sure you’re making sense.