Charting do's and don'ts

CarVsTree · Jan 17, 2007

Are you charting by exception or charting an entire progress note?

Here is one don't:

Pt. ordered cervical collar but arrived on floor without one, that is begging for a lawsuit.

TrickieTam · Jan 18, 2007

I was told never to chart "pt. fell on floor" or "pt. had a fall". Best way to say it is "pt. found on the floor". That is if he/or she was actually found on the floor...

Mulan · Jan 18, 2007

Wasn't that taught in your nursing program?

mom2michael, MSN, RN, NP · Jan 18, 2007

We were not taught charting in NS because every facility does it differently, some chart by exception, some don't and some chart with computers and some don't.

What I ended up doing was spending some time in our awesome education department going over the do's and do not's of charting and they helped me out tons. Plus, it helps to see examples of the good and the bad.

All_Smiles_RN · Jan 19, 2007

I get confused sometimes too. I had a situation where a pt of mine came close to coding recently, but thankfully we stabilized him. This was my first "big event" I had to chart about and I wrote out a long detailed synopsis of what I observed, what I did, how the pt responded, etc. A veteran nurse said I did good, but to try and keep it short and sweet. He said the more you chart, the more a lawyer has to pick apart. Makes sense, but I felt the need to chart everything as to show I intervened appropriately. I don't know if I offered much advice here... Hopefully others come through with more tips. :-)

RNLisa · Jan 19, 2007

We were always taught to chart what we see, not what we assume. Also, do not chart: Pt. appears.... (fill in the blank). We are not to chart how the patient appears, just chart the facts. Also, we were also taught that if we chart a "problem", we must also chart the solution (what we did for that problem). For instance, "Pt. c/o headache at 4/10 on scale. Gave Tylenol 650 mg PO per orders". Then, later, make sure to chart effectiveness. That is just an example of "problem and solution". I was always taught to make sure we chart what we actually did for the patient.

GFocker · Jan 20, 2007

I always feel like I havent charted enough on a patient, and when I do chart enough I usually reread it and wish I would have added more to it.

RNsRWe, ASN, RN · Jan 21, 2007

We covered charting to DEATH in school, regardless of the fact that each facility does things differently; we had a good base from which to work.

We have "checkoff" type assessments mapped for each patient, and then chart by variance. When actually writing your notes, never ever chart how a patient 'seemed'....that is, never write "Pt seemed unwilling to learn about diabetes"; you could instead write "Pt stated "I don't care what you say about diabetes, I'm not interested". State exactly what the patient said, not what you interpret him to mean.

'Pt states "I feel like I have an elephant on my chest", not "Pt felt chest pains". Always write what THEY say they feel, not what you think they are feeling.

NO judgments, meaning never ever write "Pt acting beligerantly, demanding more food. Told him he couldn't have any". Instead, you could write "1130:Explained to patient that his MD has ordered a clear liquid diet only. Pt states "I don't care, I want to chew something." Explained to pt. that the orders must be maintained at this time, but his MD would be notified of his request. 1145: Md notifed by telephone."

Pt never "says he's in pain but shows no outward signs", nor does he "appear to be in pain"; instead, "pt states his pain is Level 8 on a pain scale of 0-10. Pain meds provided per MD order." No personal opinions included.

Blackcat99 · Jan 21, 2007

The biggest NO-NO in charting is to chart in the nurses note "Incident report filled out." Although we do have to fill out many incident reports, that fact is not to be put into the nurses notes.

nursejllrn · Jan 26, 2007

After 18 rears as a LPN I had to relearn charting protocol when I went to RN school. I still wanted to write "Appears to be sleeping" now a no-no. Also I was told not to chart "found on the floor" but to write "patient noted lying on floor" some how the word "found" was a liability.?? Maybe it sounds like they had layed there forever??? I don't know. One other I can remember is don't chart side rails up x 4, that is considered restraints! It was news to me but apparantly you can only chart up to 3 side rails up at a time! Your education nurse can be a big help if you have one. They love it when staff seeks their help. At least ours does and is always very helpful. There were several other changes since I had been to LPN school so I had alot to learn. Wouldn't want a lawsuit, now that I finally have my RN. Good luck. Oh PS, this board is also a great resource for info!

RNsRWe, ASN, RN · Jan 26, 2007

After 18 rears as a LPN I had to relearn charting protocol when I went to RN school. I still wanted to write "Appears to be sleeping" now a no-no.

I had a disagreement with a charge nurse recently; I was going over student notes and found "pt seemed tired" or "appeared tired" or something like that, and I commented on it. She told me that the student was right, etc etc, it was objective data....this was NOT correct IMO, not according to everything I had learned (and much more recently than she; perhaps when SHE was in school, where she went to school, it was different). At any rate, it IS a no-no to chart what they "appeared" to be; chart what they ARE!

One other I can remember is don't chart side rails up x 4, that is considered restraints! It was news to me but apparantly you can only chart up to 3 side rails up at a time!

Actually, this will vary depending on where you are, and the facility that you're in, and their policies too. I was in one hospital where x4 was a restraint, but the one I'm in now does it routinely, NOT a restraint. And it's not like anyone is messing up, it's a hospital-wide policy that has been seen by TPTB.

I had no clue before going to school what the big deal about charting was, LOL...figured you just jotted down their vitals and what the doc said, right? ROFL...