Charting... tips

[violet_violet]

What's your advice on charting? How detail are you? Can charting too much ever come back and bite you???

As a student, I don't think there were ever an offical class on how to chart and save your butt, but what have you learned working as an RN??? Any tips, please share.

[TDCHIM]

CheyFire, thanks for the excellent post. The way you described charting would definitely make some of my future work easier! I have to say, I'm surprised that nursing programs (from the way you all are describing them) don't have their students take a documentation class. It seems like that would be a natural course for nursing students, if for no other reason than to learn how to protect themselves while charting.

[diane227, LPN, RN]

The problem is that each facility has a different way of documenting information. Some use a check list, some use computerized charting, etc. The important thing is, no matter what method you use, you have to document in a complete and concise manner. This means that you may have to do supplemental documentation on another form. If your facility does not have a specific nursing form for this, take a blank progress note and title it "supplemental nursing documentation'. Make sure you document date, time etc.

[Kaychell]

Thank you SO much CheyFire. You're post is incredibly helpful!! I've been wondering about do's and don'ts of charting!

[zippy79]

I know this thread is rather old, but I'm hoping someone's out there still browsing it.

I recently made a switch from doing 1 year acute care to doing geriatric care at a SNF. I'm not sure if it's my mind set having been trained as an acute care nurse, but the NURSE'S NOTES section on a patient's chart at the SNF I work for always drives me CRAZY! I've read people chart things like the following:

-Resident's skin afebrile (*****)

-"Resident resting comfortably in bed" when the chart is tagged for tracking uncontrollable bleeding due to coumadin therapy

And the list goes on... The question is, should I be writing an inordinate amount of narrative on a chart--- like "the patient was asleep in bed. blah blah blah"? I thought the whole point of nurses' notes is to chart by exception and focus on acute changes which are far more pertinent than the normals?

Please shed some light on this topic....

[plumflower]

charting is one of my passions!

chart objective facts. state exactly what you see, hear, smell, or touch. (please no tasting in this nursing/patient area). chart what the patient is "doing" or chart what they say with quotation marks. never assume or infer .... substantiate with facts.

i read too often "patient is resting comfortably" or "pt asleep". how did the nurse "know" they were resting comfortably? what was happening or being done that would lead anyone walking into the room to draw the same conclusion? those are the answers that you would chart.

try to never chart words like "appears", "is sleeping", or emotional type words such as "patient depressed". if the patient looks like they are sleeping, that conclusion can be drawn by stating "lying on right side with eyes closed respirations regular in rate and rhythm at 16. no visible cyanosis or pallor .skin warm, dry to touch." (yes i know it is wordy but tells a great deal)

they may be in a coma or playing possum, you really cannot "know" they are asleep. charting respirations and color at least helps rule out they are cyanotic or hypoxic or in a diabetic coma. skin warm and dry to touch lets the reader know the pt. is not diaphoretic, not flushed, and not cold to touch from possible hypoglycemia or being dead, and that you have actually come close enough to the pt. to know!

nurses cannot assess very well from peaking in the room in the dark, hearing a snore, and then leaving. what if the iv is out and infusing in the bed and soaking the sheets? (i have seen this happen, and peg tube feeds too...and i won't mention pts found in poo dried up to their armpits but not smelly enough it could be smelled from the door)

if the patient is depressed, what are they doing that makes anyone walking into that room think the same thing? is the patient crying, no eye contact, refusing to eat or answer questions, wants the room dark and tv off? does the patient tell you "i feel like dying i am so depressed." then state what the pt says that leads anyone to think the same thing.

if the pt. is combative, non-compliant, angry? state what they are doing or saying (or throwing) that makes the reader reach that same conclusion. chart "pt. with fists clenched and hitting on desk at nurses station cursing. pt loudly states "you blankity-blank so and so get me my demerol. pt threw box of kleenex at nurse and knocked over med cart."

that will make anyone reading understand that the pt was not a happy camper.

charting "pt. tolerated procedure well" may fill a blank space for a every 2 hour entry but lets the reader know zero. (i review charts weekly believe me) how do you know they tolerated it? did you ask? did they tell you? then chart "pt asked if their bladder felt better with the foley catheter now in and pt stated "yes."

if you assess an iv site infiltrated, chart what you saw and felt that leads you to that conclusion. "iv site red, swollen, cool (or hot) to touch and pt states "it hurts". site painful to touch"

never chart "pt. fell" unless you were actually in the room in direct line of vision and watched them fall. you can only state "pt. found on floor on left side and stated "i fell getting out of bed."

if you call a doctor about a patients abnormal labs values it is your word against theirs. chart "doctor informed of potassium 2.7 and hgb 4.5". don't just chart "called md and informed of abnormal labs." let me hush. i hope i didn't go overboard.

Great!

[NightNerd, MSN, RN]

I agree that this component seems to be missing from a lot of nursing school; I remember writing notes for psych, and the rest is all a blur, lol. PP had awesome specific tips! I would just add that it might be helpful to ask your instructor to provide some examples (sans PHI, of course) of examples of good documentation for specific things. Seeing the difference between a detailed note and a poor note is always helpful to me.

The other tidbit from school I remember is, "Write your nursing note in such a way that, should you collapse in the middle of your shift, another nurse can read what you wrote and continue seemlessly from where you stopped." That's all I got.

[Msterry]

Retired RN with 40+ years of experience. Please contact your nurse manager and ask if anyone from the Quality and Risk Management dept in your hospital is available to provide an in service on charting. My last position was in Risk Management and Quality. I have seen first hand the lawsuits that the Hospital loses due to inadequate documentation. Please check into this because it is more important than ever