Charting

BETSRN · Aug 3, 2005

Someone posted a question in the new nurses forum about guidebooks for charting, but I thought I'd ask here. Knowing what to chart (and where to chart since we have a lot of redundant documentation going on) is an unexpected challenge for me. Does anyone have any thoughts, advice, references on how to chart on antepartum/intrapartum flow sheets, on monitor strips, etc. What kinds of things are essential to document? What habits do you have for charting that make it automatic/second nature rather than a set-up for writer's block?

You need to get familiar with your own facility's charting system. Asking here won't do you any good as there is so much variation.

suzanne4, RN · Aug 3, 2005

I ave to agree with the above poster. Each facility has its own charting protocols. Best suggestion is to contact the educator for your area.

amber1142 · Aug 3, 2005

You need to get familiar with your own facility's charting system. Asking here won't do you any good as there is so much variation.

I disagree. My question isn't about the charting system, it's about what makes a good nurse's note and about whar routines are useful for charting. *Of course* I am paying attention to what is required at my facility. Thanks for trying to help.

SmilingBluEyes · Aug 3, 2005

Oh my, yes---ask any legal consultant (particularly a nurse lawyer or consultant)---- charting is critical and literally volumes are written and discussed in seminars about legally-defensible charting. Besides knowing your institutional policies (yes that is critical), there are other ways to 'beef up" your charting so it's thorough, concise and clear. I have a couple of suggestions:

Here are a couple of books about charting

http://search.barnesandnoble.com/booksearch/isbnInquiry.asp?userid=In0Ri5JAu6&isbn=1582553939&TXT=Y&itm=7

http://search.barnesandnoble.com/booksearch/isbnInquiry.asp?userid=In0Ri5JAu6&isbn=0874349524&TXT=Y&itm=4

http://search.barnesandnoble.com/booksearch/isbnInquiry.asp?userid=In0Ri5JAu6&isbn=158255238X&TXT=Y&itm=5

Also, being a member of AWHONN may help, as you are made aware and kept abreast of changes and issues near and dear to obstetrics.

there are also oftentimes seminars and conferences that will focus on documentation and standard nomenclature used to clearly communicate any given situation, should you be called to defend yourself. Michelle Murray's seminars are EXCELLENT----

There is also a book on standardized NICHD nomenclature/terms you should be aware of for charting (make sure your facility uses these, if you are to use them)

(example--- KNOW there is a difference in "fetal distress" and "fetal intolerance" legally---the time it takes to take action becomes important and a defined frame of reference!!!)

Here it is:

http://search.barnesandnoble.com/booksearch/isbnInquiry.asp?userid=In0Ri5JAu6&isbn=0683401173&itm=5

So in summary:

*Know your facility policies (which you are aware you need to)

*Try some of the references/books I recommended

*Become an AWHONN member

*Be on the lookout for seminars/conferences on Fetal Heart Monitoring issues, Legal charting tips/recommendations, etc.

*Be sure you address issues of consent, knowledge/education of the patient, pain issues, and ANY changes in maternal or fetal condition that are NOT well-defined in exception charting you may be using where you work. If your exception/SOAP charting is not covering it, if a jury could not get a VERY CLEAR picture of what the situation was at any given time, BASED ON YOUR NARRATIVE NOTES, you are NOT charting sufficienty and in a legally-defensible manner!

*KNOW the proper nomenclature/terminology and the standard where you practice and STICK TO IT, do NOT get creative.

I do hope this helps!

babyktchr, BSN, RN · Aug 3, 2005

Last month I reviewed a case for a lawsuit in which I had to go over nurses notes and charting. The ONE thing you MUST do is use your hospitals policy on charting strips. I have found that what is meant to be charted and what is actually charted are two different things. Any exception to standard charting must be put in narrative. You must make sure the picture you are painting is the one that is actually happening, and give a clear description of what is happening and what you did. The basis of negligence is not finding evidence that you kept your patient from harm.

NICHD nomenclature is coming, and it is exciting. It will simplify and standardize charting. Everyone will be on the same page. AWHONN is finally accepting it....woohooo.

Another really fantastic speaker is Lisa Miller. She is a midwife and an attorney. She gives seminars on fetal monitoring and the law and they are fantastic. She has a lot of insight on legal issues and fetal monitoring and is a huge proponent of NICHD nomenclature. I would recommend her highly, along with Michelle Murray.

amber1142 · Aug 3, 2005

Thanks; this is very helpful. Some of the nurses on my unit were debating the other day about whether to call decels as variables or lates, or whether to simply describe what you see (e.g. FHR delines 15 beats from baseline over 10 seconds with gradual return to baseline over 30 seconds after peak of contraction) because to actually call it a variable or a late is akin to diagnosis. The redundancy of the charting is irritating because what I just described is shown on the monitor strip and we have to mark it electronically to acknowledge it, but then I guess we have to describe it in the flow sheet as well. We also have to note that the patient is up to pee, that a sterile speculum exam was done, a lady partsl exam, the patient's comfort level, etc.

It really is a skill to be able to document what you're doing and seeing while you are doing and seeing it. What would you call that? Running narrative, concurrent documentation? It's quite different from the other paperwork: admission, triage, plan of care, etc., that you can do at any stage.)

SmilingBluEyes · Aug 3, 2005

Last month I reviewed a case for a lawsuit in which I had to go over nurses notes and charting. The ONE thing you MUST do is use your hospitals policy on charting strips. I have found that what is meant to be charted and what is actually charted are two different things. Any exception to standard charting must be put in narrative. You must make sure the picture you are painting is the one that is actually happening, and give a clear description of what is happening and what you did. The basis of negligence is not finding evidence that you kept your patient from harm.
NICHD nomenclature is coming, and it is exciting. It will simplify and standardize charting. Everyone will be on the same page. AWHONN is finally accepting it....woohooo.
Another really fantastic speaker is Lisa Miller. She is a midwife and an attorney. She gives seminars on fetal monitoring and the law and they are fantastic. She has a lot of insight on legal issues and fetal monitoring and is a huge proponent of NICHD nomenclature. I would recommend her highly, along with Michelle Murray.

excellent post. Thanks!