In this paper, by Leonard Kunka, you will find information on Medical Charting best practices and the importance of charting from a legal perspective.
Each hospital develops its own standard of charting practice, usually by taking into account the requirements set by the associations which govern health care professionals in that community. A major tension which develops is the apparent need to “document everything” in order to protect against lawsuits, and the fact that such documentation can be used by a skilled lawyer to attack virtually any health care professional. Equally problematic are hospital policies which have adopted charting protocols, such as the form of charting known as “charting by exception” (CBE) or “variance charting”. These policies are potentially the biggest area of risk for hospitals and their staff, as they provide ample and futile ground for attack by experienced counsel.
Read Leonard’s full paper on Medical Charting.