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Defensive Charting

An emergency department director was recently asking for advice when a staff member was reprimanded for charting “delay in patient care occurred due to high volume”. The scenario is quite common in many emergency departments throughout the country. Staffing is based on historical norms and there will be occasions when something unusual occurs. It is important to examine the volumes regularly and be adept enough to make changes quickly (monthly) in order to prevent overwhelming volume from hampering emergency department flow. (see Staffing By Hourly Arrivals)

In addition, on-call staffing of nurses and providers can also help alleviate these scenarios. If a department finds itself frequently using the on-call staff, there is a bigger problem to fix. But this director knew this already. What he was asking for was an acceptable statement to chart that would protect the staff member from blame as a result of poor patient flow and high volumes.

Advice given from multiple people included things like:

  • Statements like these have no medicolegal value. If there is a patient safety issue, the quality assurance process should be utilized instead.
  • This statement is unnecessary, an audit of the electronic medical record timeline will show the delays.

But I offered a slightly different view of the scenario.

Why does this staff member feel the need to document this statement?

The staff member who wrote this was doing it for a reason. For example, everyone knows it’s busy in the ER on Monday and by Monday night holds are accumulating which carry over into Tuesday morning. So why is this staff member documenting this statement? I suggested that there might be pressure on this person to perform to a standard that they feel can not be attained when volume causes delays. There may be a policy, rule, or expectation that is unreasonable or unattainable on high volume days. Blaming this staff member instead of recognizing the volume issue, caused this person to document the statement. They are basically saying: I could not do X because volume was too high.

So yes, this statement is not helpful and not protective for the hospital. But future statements like this can be avoided by changing the policy, rule, expectation or focusing on better high volume protocols instead of reprimanding the staff. This kind of defensive documentation arises from a need to protect oneself from their own supervisors and it is completely avoidable by changing the culture and addressing the underlying problem.


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