Every nurse who enters the field has probably underestimated the central role that charting plays on a daily basis. Accurate record keeping is key to a successful career with a priority to protect health information and ensure patients receive the correct treatments.
What is Charting?
In nursing, charting refers to the practice of documenting any and all care delivered to a patient, including but not limited to patient status, diagnostic information, test results, medications administered, and procedures performed. It’s no overstatement to say that nurses live and die by their charting, and that charting successfully is one of the most fundamental skills a nurse should have.
For many nurses charting can be a challenge. We’re sharing the following with tips on how to chart better, and common mistakes to avoid.
Why Good Charting Is Important
Charting is critical to patient safety and effective treatment. It also becomes part of the patient’s medical record, which is protected by law.
Nurses typically spend more time with patients than other medical staff and clinicians in any care setting, from hospitals to home health care. Because of this, nurses will often have the most insight into a patient’s status, mood, changes to health, responses to medications and treatment, and other key information.
By recording, or charting, this critical information in a clear and concise way, others on the healthcare team will have access to this information. For example, by reviewing a chart, a physician can have a better understanding of what to expect from a patient, and without having to ask repetitive questions.
3 Practical Tips for Successful Charting
Here are three of the most important tips for any nurse looking to chart effectively.
1. Take Notes As You Go
Charting will be easier if you are keeping up with all the information you will need to chart throughout your shift. Take notes as you go that include key changes to patient status and treatment, but do not include any sensitive information that could violate the Health Insurance Portability and Accountability Act (HIPAA).
2. Be Consistent
Remember that your charting is reviewed by multiple healthcare team members. So any shorthand, abbreviations, initials, or acronyms you include should be standard language that other professionals would likely know. When in doubt, spell it out so you can be sure that others will understand.
3. Be Thorough
Be concise so that your charting is understandable, including all critical information that could affect the health and safety of the patient. Be specific and always include objective data. Even if it seems like an insignificant detail, if you notice it, it may be important to a doctor or other nurse later.
Avoid These 3 Big Charting Mistakes
1. Don’t Chart All at Once
Charting in real time as waiting until the end of your shift to chart all of your patient notes can lead to delays in care and important information being left out. Whether it’s taking notes as you go, or finding moments to update the patient file, avoid the mistake of charting all at once.
2. Incorporate Technology
Becoming an expert in the charting system at your facility or employer is a key part of your job. Learning only the bare minimum of what you need to chart will not benefit you, your team, or your patients.
Instead, take an open-minded, technology-positive mindset. By learning keyboard shortcuts, hotkeys, steps for automation, and other important practices, you can save time, be more efficient, and focus more of your attention on patients.
3. Don’t Chart Your Opinion
When charting, always stick to the facts and objective data. Putting your subjective opinion into the medical record can cause misunderstandings, inefficient care, and potentially even negatively effect treatment.
This isn’t to say that there isn’t a place for a nurse’s opinion on patient care. Instead of expressing these in the medical record, there are other avenues for patient advocacy, including written and verbal communication.
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