To protect yourself, you should always follow the procedures in the manual and do not deviate from them even if asked to do so by a supervisor. If you act contrary to hospital policy, you are not acting as their agent, and you could be fully liable for any incidents that result. If your hospital does not have a Policies and Procedures Manual you should try to institute one. If your hospital has a manual, but the manual does not cover a situation that has arisen, take steps to have the administration add an item to the manual so that the situation will be covered in the future. Your Risk Improper charting is a major issue in the vast majority of all malpractice suits.
Most nursing schools teach charting in terms of good medical practice.
However, you also need to know how to chart symptoms in terms of good legal practice - in other words, how to chart with a jury in mind. Do not record opinions or conclusions, just facts . If you record your opinions in a medical chart the patient's attorney can easily throw doubt on your judgment. But if you stay with the facts the jury will tend to see you as a competent and professional. Include the patient's description of his or her symptoms, even if the description seems incorrect.