Maintaining the medical record
One aspect of critical care nursing that is not necessarily unique, but is very important and has strong legal implications, is maintaining the patient medical record. Waxman emphasized the importance of accurate and thorough charting. When charting, it is important to report the facts as events happen, she said, rather than waiting until the end of shift when memory and fatigue may preclude accuracy and completeness. It is also important to avoid adding opinions or using unprofessional language, as the medical record is a legal document and may be requested by owners, veterinarians, or legal and regulatory entities.