Charting... tips

chloecatrn · Sep 4, 2010

Charting too much, as long as it's ACCURATE and FACTUAL, isn't awful... especially in a bad situation. That being said, for most patients, I've always just charted the minimum. My last job had a computer based charting system, and it was very easy to go through and click the boxes. Any time a patient had a change in status, a lab value was out of range, had a complaint or question I couldn't answer or solve in an expedient manner, or any time testing or a procedure was delayed for an unreasonable amount of time or a med didn't arrive from pharmacy within our facility's parameters, I charted an extra note. I also charted every time I called a physician about a patient's complaints/status. I'd just do a brief note saying who I spoke to, what the complaint/problem was, and what the outcome was. Some people would probably say that was even too much, but better to be safe and be able to protect myself in case of an emergency later.

Scarlette Wings · Sep 4, 2010

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.

Redhead28 · Sep 4, 2010

I'm old fashioned in the fact that I believe in writing notes. I know that the new thinking is charting by exception but this tells you nothing if you have to go to court 20 years from now. I work pediatrics and the "pt" the child can go to court until they turn 21. Your charting should tell the story of the day... So my first note usually starts... Assumed patient care,.

bhenry2010 · Sep 4, 2010

Accurate charting is VERY important. i was the same way throughout nursing school, i didnt realize how to chart or what was needed along with it. You will learn so much when you get our there and start working as a nurse. :lol2:

ellehcim · Sep 4, 2010

As a new grad with

CorpsmanRN, BSN, RN · Sep 4, 2010

Cheyfire, that was great!! Thanks! During preceptorship I liked reading notes from prior shifts just to see the differences. It was interesting to see how some only did the exceptional charting and others did so much more, as well as how they described certain situations.

Like the OP, we didn't get any charting classes (which I'd think would be important since our instructors always mentioned "if you ever have to go to court..."). Thanks again for the tips.

brownbook · Sep 5, 2010

I don't know if it makes sense, but I often hear, the less you chart, the less a lawyer can try to trip you up with?

One thing that helps me is to think (I am really showing my age) but there was an old police show where the officer would interview the witnesses or victims, etc, and his tag line was "Just the facts, mam or sir."

HamsterRN, ADN, RN · Sep 5, 2010

In terms of legal issues, there are people who specialize in this and, at least in my area, they give talks fairly regularly (legal nurse consultants). The most interesting thing I learned at one of these presentations was that it's rarely a minimalist charting style that gets you in trouble in court, it's unnecessary charting that opens the door to legal liability. Consistency is the key to legally "safe" charting, and the more unnecessary charting you do the harder it is to be consistent. As long as you chart accurately, everything that is truly relevant, and to your facility's standards, you're pretty safe.

That being said, I like to keep charting, specifically my note, to what other's caring for the patient need to know, no more, no less.

DogWmn · Sep 5, 2010

Hmmm interesting, we had a "charting class" when I went to school in the dark ages. All of our notes were evaluated by our instructors every day, when we first started we had to write it up first on a paper, get it approved then chart it for real. We also had a bound notebook full of charting examples both good and bad that we had to read and discuss in class.

Excellent post CheyFire.

Scarlette Wings · Sep 6, 2010

cheyfire, that was great!! thanks! during preceptorship i liked reading notes from prior shifts just to see the differences. it was interesting to see how some only did the exceptional charting and others did so much more, as well as how they described certain situations.
like the op, we didn't get any charting classes (which i'd think would be important since our instructors always mentioned "if you ever have to go to court..."). thanks again for the tips.

i so understand what you are talking about. i always try to include documentation in anything that i do to help educate the staff. it is not that nurses do not want to chart well, so many times they have not been taught the practical points of how to do so. (of course having the time to chart is also a huge factor.)

i always take my nurses notes into a patient room with me when i hang blood, or now i actually lug the huge cow (computer) with me. while i am doing my first 15 minutes at the patients bedside for a blood transfusion i also use it to chart the education and all that i am doing about the blood.

charting by exception is workable but there are just too many variables. i really love legalities and writing and this aspect of nursing has always been a blast for me.

diane227, LPN, RN · Sep 6, 2010

I am a major note writer. I hate check boxes and have participated in malpractice cases where check boxes came back to haunt the nurse (not checked, not done). You should learn to document factual information using patient quotes when you can, especially when there is a problem. I avoid vague terms like "patient stable" or "resting comfortably". You should be specific. When you do any teaching, it should be documented. Also, if you provide handouts or information from the internet, reference it specifically. If you use a care plan to document your teaching, reference it there. When you have a problem with a patient, you should document what the problem was and what you did about it. And again, be specific. Remember that you need to document who you told about the problem...doctor, charge nurse, supervisor etc.

There are medical/ legal texts that you can buy that will give you specifics on how to write a note. Also, do not use generic terms like "obtunded" because words like this have different meanings to different people. Write specifically what you see such as "patient does not respond to verbal stimuli. Patient does not move when touched or shaken." etc.

If you contact a doctor for an issue and he/ she gives you orders, write the orders and document in your notes that you called the doctor and orders were given. And when I write the order I write it as follows:

Date, time:

Serum K+ at 15:00 hrs 2.5

NS 1 liter with KCL 20 meq at 125/hr.

KCL 20 meq po X1

Repeat K+ in am

T.O DR._______/ My name and title

A nurse new to our unit taught me to do this. This way it is clearly documented why you called the MD.

Also, if you leave a note for social work, case management, dietary, etc, include those actions and what the referral was about... what ever the patients concern was.

Make sure you also document any information given to the family.