Charting?? What is it?

charting: your worst nightmare and best friend

I know this tells you nothing, but once you've learned about charting, look back at that quote. Trust me, it's entirely relevant.

In the meantime, check these links out:

http://www.malenursemagazine.com/charting.html

and last but not least, a good internal thread on charting for you:

https://allnurses.com/forums/f205/examples-charting-138835.html

Enjoy

Charting is documentation to describe information you found out by assessment, review of history, etc and then what you will plan to do about it. This is followed by documentation of what you actually did. The final step is what those interventions have done to change the initial problem.

This includes things like medication, vital signs, response to medications, other things that you find important to convey to others. All of this has to be done in a manner that can be understood and stand up to legal review.

It is probably the thing we all hate and know it has to be done.

Documentation of observations, nursing interventions and the patient response. In addition, what other discipline was contacted for further intervention (ie, the physician, physical therapist, nutritionist, etc..

It can be the best friend and worst nightmare, because it can take time, occasionally, things are forgotten about, which can bite in the butt later, and in addition, depending on what you are documenting, careful thought has to be placed in it, because, especially in this computer age, once documented, it may not be taken back. Sometimes, there are things that may be implied to show what another did not do, such as how many times a physician was paged to tend to a crashing patient before he actually responded. Numerous forms, flow sheets, teaching, protocols, many redundant and unnecessary things that take away from patient care. It all adds up to document care, or the nurse can face liability.

Nightmare charting example:

When a patient is admitted to your floor, you are required to list all of their medications the patient takes, the dosages, routes and frequency of taking the medications on your admission documentation.

For the frail elderly and chronically ill, this can be a dozen or more.

Some patients do not know the names, or dosages of what they take except for a vague idea of "pink pill with breakfast".

You are now playing detective asking family to bring in the medications or calling caretakers for information.

To complete your required charting is going to take a really long time now, and your other patients needs aren't going to stop for charting.

Here is another charting nightmare: patient doesn't speak English, no in person interpeters, and the telephone interpeter line tells you that you have to wait at least 40 minutes for a person that speaks this particular language (maybe they are not on duty yet?), and the person seriously needs orientation and teaching.

charting: your worst nightmare and best friend

That's it!!!!

It's just a plain fact in nursing, no matter what kind of nursing you do: you need a clear, concise record of everything you did for a patient, each interaction you had, what treatments you gave, what you observed.

Without documentation such as this, you have nothing to support yourself should someone claim there was improper treatment (for example).

It does take away time from patients; it theoretically takes time away from your family as it can (depending on circumstances, of course) require you to stay longer until your work is finished. And you're not finished if your charting isn't done. On the other hand, it's not like it's volunteer work; most professional positions do require you to stay to complete a task or whatever before heading home. You do not see a professional jump from the desk at 4:59 pm and shout "time's up! Guess that project's not getting done, huh?" At least, not ones that plan to be there very long

Legal wise....if it was'nt charted, it was'nt done.

Charting is what you do for at least five minutes for every one you spend in the patient's room. If you're lucky...it tends to be more.

It's your legal CYA that you did everything you needed to do to care for the patient. Which also means that you have to double check any charting done by the tech, since you're ultimately responsible for the patient (like having them chart that a patient w/high skin risk was on their back the whole shift when you KNOW you turned them every two hours).

It's filling out all the protocols and papers that are required by your facility to be compliant with all initiatives, whether they be medicare, facility specific, etc.

It's the number one thing that covers your butt when you get called in to talk to your manager about patient issues as well in my experience...luckily all of my "talks" I've been able to show that I wasn't at fault b/c of my charting.

So worst nightmare and best friend at once is a good description!

Legal wise....if it was'nt charted, it was'nt done.

Yep.

Like if you did a dressing change but forgot to chart it...if that patient ends up sueing the hospital for something (infection leading to loss of a limb for example), your lack of charting it means you didnt do it. You cant prove you did it.

I'm awaiting my acceptance letter into nursing school, but in the mean time I read alot on allnurses.com...my question is, what exactly is charting that I hear everyone complain so much about? I'm already fearing it and I'm not exactly sure what it all entails lol. Is it time consuming? I'm pretty sure I know the gist of it, but not too much else..I'm also reading that alot of nurses aren't getting alot of one on one time with their patients, which to me, is really important. I want to work with either really sick people, like ICU or ER..or maybe small children or the elderly...and not too sure if in a hospital setting either...I just know I will really value the time with my patients...anybody else feel this way as well and what kind of position does this sound like? Thanks!

Thank You for your question!! It is helping me alot with a paper I have to write about the charting duties of a nurse! I have just been accepted into a nursing school for the spring semester and I am real nervous about charting!!!