You’ve likely heard other nurses say, “If it wasn’t charted, it didn’t happen.” Proper documentation can sometimes be a pain, especially during a busy shift, but doing it right protects and helps both you and your patient.
If an issue comes up, you can use your good documentation to show you did everything you could to give the best treatment. And other health care professionals rely on your documentation to figure out what’s best for your patient.
So, whether you’ve been working in the nursing field for years or just a few weeks, here are some important tips to follow in your charting.
Why Good Charting is Important
Charting isn’t just another duty on your checklist to check off. What you write in a patient’s chart can be used in many ways. Here are several reasons why practicing good charting is important and necessary:
- It helps determine if treatment is working or needs to be adjusted.
- Good charting shows trends that could affect the patient or future patients.
- Other health care professionals like doctors or nurses on later shifts will read it to know what’s going on. It’s how you can communicate with other health care professionals when you aren’t there.
- Insurance companies and the billing department use patient charts to determine bills and payments.
- It will be used if there are legal issues like malpractice cases.
- Researchers use information from charting in many studies.
- Inspectors use charting as a main source to see if a facility is following quality care guidelines for credentialing.
- If something is missed in charting, it could hurt or even kill a patient. One example is if the intake nurse fails to chart a medication allergy.
General Charting Guidelines
Whether you’re charting by hand or on the computer, there are guidelines for charting best practices that apply to most jobs.
- Double-check you are charting in the right chart.
- Know your facility’s policies.
- Chart facts and be as descriptive as possible.
- Be precise in your charting and measurements.
- Write so other people can read it.
- Chart as soon as you finish care.
- Record the proper date and time.
- Write down the date, time, message, response, and any other meaningful details when you receive phone calls.
- Chart preventative measures, like the use of bed rails.
- Chart the time and date of any medication administration, including any necessary information, like the route, dose, and vital signs.
- Record changes or reactions to medications in a patient’s condition.
- Ask questions if something seems off. Sometimes medication orders get transcribed or ordered improperly. If an order seems suspicious, call, and verify.
- Use the 24-hour clock when noting the time.
- Chart opinions. If you have to chart what someone else said about an event, use quotations and make it clear who said it.
- Chart before you’ve done anything. Things can change quickly!
- Chart symptoms without also listing how you treated them. If a patient complains of pain, what did you do to treat the pain?
- Use abbreviations not approved by your facility. Some abbreviations are outdated or too easy to mix up with other abbreviations or words.
- Alter records. Not only is this a crime, but it can hurt your patient. If you need to add additional information, make it clear it was added after the original chart and label it with the right date and time.
- Assume that a previous shift’s charting is perfect. If something in the charting seems off, ask questions and try to figure out if maybe something got missed. This is especially important with medications that might have been administered last-minute at the end of the last shift and not charted.
- Leave blank space. Someone could come back and alter information by adding notes to spaces.
Although handwritten, physical charts for patients are becoming less of a norm as more facilities adopt technology for charting, you may still find uses for proper handwritten charting practices.
- Take the time to write clearly.
- Make sure the date and time are properly recorded.
- Use a black or blue pen.
- Make proper corrections if you make an error, according to your facility’s policy. Usually, that means you draw one line through the error and write the date and your initials next to the line. Any errors need to be legible.
- Keep charting and notes out of sight and access from other patients or the general public.
- Chart with any color besides black or blue (unless your facility has other approved colors).
- Chart with a pencil.
- Erase an entry.
- Scribble out any information in charting so it can’t be read.
- Use abbreviations that could look like something else. Your facility will usually have a list of abbreviations to avoid.
Many facilities and services have made the switch over the past decade to charting software. Using technology to chart has a lot of benefits. There are many safeguards built into the software itself to prevent problems like giving medication too soon or tracking who accessed what information.
But even with the new advances, there are still tips to keep in mind when doing computer charting.
- Log off or blackout your screen when you step away from your computer.
- Take the time to make sure you aren’t rushing through commands. Sometimes, we’re so familiar with the software that we can navigate through it without thinking, but that can lead to errors.
- Pay attention to any prompts or warnings. The software has safeguards for a reason.
- Write as much as you need to do complete charting. Most charting software has character limits, and it may be easy to just stop when you reach the limit. But complete charting means writing down as much as possible to give a clear and complete picture of patient care.
- Ignore warnings or prompts, even if you’re familiar with them or expect them.
- Rely on the software. Although there are many safeguards and processes built into the software to help you, don’t rely on it entirely to catch every mistake.
- Leave your screen up and running where anyone passing can read the information if you’ve stepped away.
- Use abbreviations not approved by your facility. Although computer charting eliminates the chance of mistaking an abbreviation for something else like handwritten charting does, some abbreviations are outdated or unclear, even when they’re legible.