Making charting intelligable

  1. The only chance I usually get to chart is toward the end of my shift and by that point Im worn out and frazzled,which reflects in my charting,my handwriting is more illegible,I forget some elements that went on with the patient and the interventions,its not as organized as Id like it,we use narrative charting.
    Charting is important,in many ways,and Id like some ideas on what others do to make there charting clear,organized,systematic,legible,concise,intelli gable and complete.
    thank you all and happy new year,watch out for those resolutions,they lead to disappointment.
  2. Visit ohbet profile page

    About ohbet

    Joined: Jun '01; Posts: 430


    Keep a small notebook with you and when your at your patients room note the time and the events and what you did. Do this with all your patients. keep a small journal and at the end of the shift sit down and chart. It will all be late charting but its a narative of the shift and accepted, also you can follow up your prns in your charting as a narative. I used to keep a voice recorder with me and I dictated my notes and when I got to where I could chart, I would go hide somewhere and write my notes down. I cleared my recorder every shift.
    Just a thought
  4. by   LadyZad
    To help keep track of all the events that I want to chart on later, I make small notes on my notes about the patients (I call my "brains"). Such are 0900 darvocet next to my report on a particular patient. Or 1000 dressing changed. And then later when I have time, I sit down and write out the narrative but I have the basics written down in one place and I just refer to that.

    I also recommend computer charting. If your facility doesn't allready have it, they should! No handwritting problems, no messy lines crossing out mistakes. And it's much faster to type something than to write it out!
  5. by   Tweety
    I bring my report sheet with me in the room and make notes in a different color ink (i.e. suctioned patient at 22:15), so it stands out later. But I do get scattered and then forget things, or get lazy, but I'm like you, when I chart at the end, it's like "just let me get this paperwork finished and get outta here".
  6. by   nursedawn67
    Everything gets wrote on my 24 hour report (drsg changes, prn meds anything unsual) this way when I chart I look at that and remember what I need to add.
  7. by   P_RN
    One thing that helps ME (and maybe only me) is when I do something to just say outloud.....10 o'clock darvocet.......10:25 suction....somehow it helps me recall. It's kind of like in a code where you say D50 @ 6:37 ......or whatever......
  8. by   jones58
    Hey Ohbet, I know exactly what you are talking about. I like to sit down and write nurses notes halfway through the shift about things that have happened thus far, but it doesn't always happen. Sometimes things are happening so rapid. Pts don't realize you are suppose to write about everything you do with them. The next pt. who wants their meds, doesn't care if you need to write something about the previous pt. They don't like to wait. Lots of times at the end of the shift, I feel the same way you do.
  9. by   ohbet
    Well thank you guys,these replies have been helpful.