Charting is another overwhelming process in the world of nursing but one of the MOST important traits in the career of healthcare. When I started as a new nurse, my preceptor overemphasized the legality of everything because we basically should avoid going to court. We talked about this more than anything else and I didn’t know if I should be pleased or scared.
My preceptor would literally time my activities and if my documentation took more than 10 minutes, she will make these remarks about me going to court because I couldn’t stop charting to go get help and the patient died. I carried a notebook around to remember things and she would hide it or throw it away so I wouldn’t rely on anything but my brain/memory. I didn’t precept that way but it taught me a valuable lesson, to not get offended (bc I was!) but simply do better.
Documentation and being efficient was everything to my preceptor because it showed competence. That was many many years ago but thank GOD I never went to court and till this day, she was nothing less than a great mentor so to spare you from further rambles, here are some tips that helped me document patient care:
5 Tips to Think About when Charting
- Your charting should be as objective and relevant as possible: if your patient load is too stressful try to address the most important body systems on patients; cardiac, neuro, resp + the focus (e.g. knee laceration) otherwise, a capillary refill, skin turgor..etc. will only explain so much. Good charting has the 3 C’s; clarity, conciseness, and consistency.
- Pain and abnormalities are properly addressed: good charting reflects what you do as a nurse and how you address the patient’s problems. If the BP is 188/99, what was done? any interventions? did you notify the doctor or was the doctor aware? was the patient’s activity before taking the blood pressure? A LACK of documentation/appropriate actions can lead to consequences.
- Will the oncoming nurse be helped or hindered by your charting: hospitals are 24-hour operating facilities but nursing shifts are NOT, so previous documentation should be as reliable as possible. Good documentation helps the following nurse focus on the task at hand and not on the tasks that should have been completed previously.
- Avoid late entries: sometimes better late than never is accepted but overall suspicious chart activities need to be avoided because it’s a liability. The brain can only remember so much and then it’s sketchy… Avoid making late entries a habit and chart as soon as you can to avoid inconsistencies.
- Buy a book about charting: some of these tips came from a book (it’s not sold anymore) and personal experiences. I purchased the book when I first got out of nursing school and although it’s outdated, great documentation will never get old! so don’t be afraid to use older materials, references, or whatever else to improve your charting:
What not to chart
- Disputes/disagreements: use incident reports, not the patient chart.
- Opinions, slang, or anything political (race/gender/religion): just don’t do it.
- Things that didn’t occur: do not preemptively chart medications or document treatment not yet given or started.
- Avoid summarizing: this is to decrease assumptions and confusion. Stay objective about diseases. (signs, symptoms), treatments, procedures, and tasks completed or in process.
- Don’t rely on second-hand information or report: only chart what you have witnessed or performed.
Additional Help
- Principles of Nursing Documentation: a pdf book by ANA to guide your nursing documentation skills.
- Abbreviations, Acronyms, and 8 common Charting Mistakes
