Proper charting?????

[jennilynn]

I Have never been reprimanded for my charting skills, but, personally, believe that I have a lot of room for improvement in this area.

We chart by exception and have an area for additional data. So, typically, my charting is as follows:

Assessment info- charting by exception on not met criteria.

POC

Education

In the additional data area I always put a comment at the beginning of the shift. Example: pt alert and oriented, sitting up in bed. No complaints at this time. Encouraged pt to call for assistance. Call light in reach, bed alarm on. Will continue to monitor.

I chart pain every 4 hours, follow up, if medicated within the allotted time (1 hr IV, 2 hrs PO)

If medicated for pain, anxiety, sleep, change in drip rate, etc I chart in the not met criteria and then again in the additional data as well as emar.

I don't chart if they are on the call light all night. I do chart if there are complaints of any kind.

I end the shift with a comment of report given to oncoming shift.

I see people that chart something every time they are in a room, which is every hour, by our facility's standards.

How do you chart? Do you use nursing terminology or just plain speaking terms? What is too much? What is not enough?

Just looking for some ways that others do things to see if I'm on the right track.

[Asystole RN]

"Proper" charting is a subjective topic that is highly dependent upon the policies of your employer, the needs of the patient, and your personal charting style.

Where I work we use a hybrid system of charting that is partially computerized with some paper charting.

I have worked where the Nursing Risk Aversion Manager wanted us to only chart what was called for on the computer charting with no nursing notes added unless there were extraordinary circumstances. I worked in another place that pretty much left it up to the nurse to chart what they though was pertinent.

On all of my patients besides charting the typical vital signs I chart their mood/activity, pain, cognitive status, and the tolerance of my interventions.

[classicdame, MSN, EdD]

we have electronic charting, which is basically checklists on a screen. We discourage narratives. While our BON is not specific about charting they do require enough information to make sure the whole picture is represented. I like to focus on the chief complaint. If the pt has COPD then I would record o2 sats frequently and whether or not the pt is ambulating, sleeping, on o2, etc

[BrandonLPN, LPN]

Out of curiosity, why do hospitals seem to discourage narrative charting in favor of "click and point" flow sheet charting? In LTC we rely heavily on narrative charting in the form of nurses notes. To write a coherent, relevant and informative nurses note is an art. It's not as easy as one would think. I've gotten very good at them, and I feel like it's a valuable skill to have. Is there a reason it's discouraged in acute care? I personally hate electronic flow sheets.

[Asystole RN]

Out of curiosity, why do hospitals seem to discourage narrative charting in favor of "click and point" flow sheet charting? In LTC we rely heavily on narrative charting in the form of nurses notes. To write a coherent, relevant and informative nurses note is an art. It's not as easy as one would think. I've gotten very good at them, and I feel like it's a valuable skill to have. Is there a reason it's discouraged in acute care? I personally hate electronic flow sheets.

To protect against litigation. Narrative notes tend to be open for interpretation and are common sources of damaging verbiage for the plaintiff.

There are two common ways in which nurses sink the defendant's case, either they use inconsistent verbiage/inappropriate terms or they conduct inconsistent assessments. Point and click sometimes does not tell as much of a clear story but it can tell a more accurate and consistent story.

[chevyv, BSN, RN]

We chart by exception as well with all paper charting. I also just completed a one day seminar on charting to keep you out of the courtroom.

I work in behavioral health but many of my pts are also medical. I chart assessments, vs, complaints and follow ups, like you. I also chart on every pt on our 24 hr board (which are q15's, sos's, medical, prn's, etc). I don't chart everytime I interact with pts or am in their rm or I would never get out.

I am learning to word my meanings more carefully. I used to chart physician aware. I now chart "Discussed or consulted c physician. No new orders." I learned that many physicians will deny knowledge of being aware of something when it comes to the courtroom.

As far as terminology, I always write out units for the amount of insulin d/t so many preventable errors. Our facility has a sheet on acceptable nursing terminology we can use.