Charting 101: 3 Easy Tips to Save Time and Improve your Skills

Not to mention that the nurse coming on after you, would love to be able to competently take care of the patient using their chart to have all the knowledge they need to succeed.

All of these things start with charting accurately and in detail!

But don’t worry, let’s break it down and make it easy!

Start With The Three Golden Questions:

1. What did I see?

Example: Patient A’s heart rate went into the 130’s around 0930, just after you have come on shift. Document the heart rate and the time. Then…

2. What did I do?

Example: I assessed Patient A, obtained up to date vital signs, observed for hemodynamic changes (and specify- shortness of breath, etc.) or asymptomatic, and called the physician who gave instruction to administer a beta-blocker. Document your assessment, up to date vital, medication administration, and the physician’s phone call including the exact date, time, and what was said.

3. What was the outcome?

Example: After medication administration, I obtained up to date vital signs which included a heart rate of 96 and assessed Patient A to make sure they were no longer having any symptoms. Document the assessment, up to date vital signs and resolution.

Repeat these three questions for everything that happened with each patient during your shift!

There you have it. Now if that episode ever comes into question, your license is covered. The next nurse now has the resources to accurately care for their patient. As a bonus, you earn respect from the physician for accurate and detailed charting! Its a win-win-win!

Now let’s go on to some general do’s and don’ts of good charting:

Do:

1. Use abbreviations according to policy
2. Chart preventative measures such as whether bed rails are in place (and patient education!)
3. Document refusals of medications and report them to a physician
4. Try to document as you go since the information is fresh
5. Record every message to a physician- include date, time, name, and what was said
6. Tell the whole story with as much detail as you can
7. Write “late entry” if you have to go back and add something to your documentation

Don’t:

1. Chart a symptom without charting what you did (see the golden questions above!)
2. Use abbreviations that aren’t widely accepted or can mean different things
3. Document using imprecise measurements (ex: soaked, a lot, a few, etc.)
4. Chart ahead of time (this can be considered fraud)
5. Alter previous documentation (also illegal)
6. Chart what someone else said or did unless absolutely necessary for the scenario (and use quotes if you must)
7. Write your opinions, only observation

Always double-check:

1. You’re on the right patient
2. The documentation reflects your scope of practice
3. You have completed all mandatory documentation

Now you can go home knowing that your patients are well taken care of. At the end of the day, that is why we became nurses, isn’t it?

Do you have any charting tips or tricks? Let the Capsol community on

https://www.nso.com/Learning/Artifacts/Articles/Do-s-and-Don-ts-of-Documentation

http://www.hpso.com/risk-education/individuals/articles/Documentation-Dos-and-Donts