The chart is a written document of the care given by the healthcare staff to a patient. All the information about each dialysis treatment, from the smallest to the very obvious, becomes part of the patient’s medical record. Accurate documentation in the medical record makes continuous follow-up of each patient’s response to treatment highly possible. The patient’s record is basically maintained to provide a simple way for staff to share vital details. While each member of the healthcare team have different roles to play when it comes to proper documentation, what binds them together is the ultimate goal of providing the best possible care to the patient. The nephrologist uses the chart as a basis to prescribe medical treatment. A nurse utilizes the chart as a diagnostic aid for the team, and a dialysis technician makes use of proper charting as a guide for quality assurance. The patient’s chart is a legal document, admissible in court as evidence of care the patient did or didn’t receive. The dialysis technician should always remember that if something was not charted, in the eyes of the law, it was not done. Legally, you are responsible for what happened as a result of your actions.
How the Dialysis Technician Should Write an Entry in the Medical Record
1. Learn the proper charting procedures for legal purposes.
Each facility has its own policies and techniques for how to document patient care. Learn yours. Usually, entries can be written in print or in script as long as they are readable and in black ink.
Due to the number of patients staff members have to handle, acronyms are acceptable to some extent. For example, “J. de la Cruz. D.T.” instead of “Juan de la Cruz. Dialysis Technician” may be adequate. Initials should always match the corresponding signature. Ultimately, only use abbreviations and initials that are approved by your facility.
Typographic symbols indicating that the words or phrases above it are to be repeated are strictly unacceptable. Erroneous entries could lead to legal questions if the chart is used in a court case.
4. To correct errors, the dialysis technician should draw a single line through the wrong material, and write “error” or “mistaken entry” (ME) above it.
No entry can be canceled, erased, altered, or destroyed unless previously indicated.
To prevent your colleagues from adding any entry that you didn’t do, draw a single line through it.
Be sure to be accurate and factual when charting. Entries that are illegible are considered legally unacceptable information. Never sign another teammate’s entry.
There are cases when a page of one patient’s chart is accidentally placed in the wrong chart. In order to avoid this, each page should be labeled accordingly. The use of a stamp with the correct addressograph plate is normally acceptable.
Always remember that charting provides data for continuity and planning of patient care. It documents proof that care was rendered. On the other hand, charting provides a permanent legal record to protect you, the patient, and your teammates. Proper documentation is the best communication tool for the entire healthcare team. Be sure to include detailed descriptions when you chart about patient complaints, such as the severity of their pain and discomfort.
9. Don’t draw into conclusions. Only use objective terms when describing patient behavior.
Instead of calling your patient “rude” or “noncompliant”, you could document “Patient tried to hit dialysis technician with his walker.” This would leave nothing to uncertainty. Anyone who would read that will know exactly what the patient is like.
For instance, understaffing is not a valid reason for a delayed response to an emergency. While staff shortages can directly affect patient care, they should only be reported to the manager in a confidential manner.
All the dialysis technician has to do is document the facts of the incident in the medical record, but not mention the report has been initiated. Incident reports are confidential administrative forms that should be kept private by the facility’s management.
The poor choice of words will get you in trouble. Words that raise any doubts will suggest an error was made and patient safety was compromised.
How the Dialysis Technician Should Use Electronic Charting
1. Never share your password or computer signature with anyone.
Electronic charting may be used by your facility instead of paper charting. In this case, all documentation is done on the computer. To make sure that the electronic chart is not tampered with, never give out your password to another dialysis technician, nurse, or even a doctor.
Computer errors cannot be changed or edited once they are stored as entries. If possible, type an explanation into the file, with the date, time, and your initials.
Accidental deletions of parts of the permanent record are possible. Having a backup is a vital safety feature that every dialysis technician should be aware of.
Patient documents are confidential, and should be left that way. Don’t leave information about a patient on a monitor where others can easily see it. Consequently, printed versions or excerpts should also be attended to at all times by the dialysis technician.