question about charting

purplemania, BSN, RN · Oct 21, 2003

Do the colors refer to color of ink? Why would it make a difference if people are dating and timing their entries? I guess if the chart got pulled into court one could discern copies from originals---but not really, since color copiers exist. Anyway, we ALWAYS sign, date and time our entries. The night shift is responsible for adding a note that 24 hr chart checks were done. This may not be necessary in your facility. Hope that helps.

Trauma Columnist · Oct 21, 2003

Is this in a nursing home?? I work in a midwestern level one trauma center and our charting is completely computerized.

S5777 · Oct 21, 2003

whats your charting like it being computerized what do u chat and i ment the colors of ink being used sorry for not explaining

Katnip, RN · Oct 21, 2003

Our facility (a hospital) requires that we do everything in black ink. supposedly it shows up best when copied, which I believe is true since we don't use color copiers. We date and time each entry. One reason is, if a patient has been assessed for something and a change has come up, the change needs to have a time of when it occured.

Things that we chart: some baseline assessment info, anything that deviates from normal, anything a patient may say or do that could come back and bite you later, what you did about problems, when the physician was notified, dressing changes, procedures performed by anyone and the pt's reaction to it, when a patient goes off the unit and comes back on.

Also, in nursing school we were taught that all legal documents are to be done in black or blue in, no colors, and charts and everything in them are legal documents. We haven't gone to computerized charting, but it's being introduced now unit by unit.

txsugarlvn · Oct 21, 2003

The questions aren't dumb at all! It's great you are making an effort to educate yourself and find out more about charting.

In all the facilities I have worked (nursing home, dialysis, hospital, etc) we have charted in black ink only. Back long ago, many many years, charting was done in a different color for each shift. This changed because of legal problems. When xeroxing the patient's chart, red and green don't show up very well and neither does blue ink. So, the standard was changed to black ink only. I don't know about other states. I'm in Texas. Or even about other cities in Texas but from understanding, black is the standard for San Antonio.

What to chart? This depends on the facility as to how in depth they want you to go. I've had some say I charted too much and it put the facility "at risk". The facility will always protect itself so be sure YOU protect your own behind. Don't write a book but chart pertinent info and be precise. For instance, if you check on a resident (or patient) and they are asleep, don't just write "patient sleeping". You have to be more precise. One facility I worked at said to write it more like this: "1630 Resident appears to be sleeping. Eyes closed. Breathing even and steady."

The same for charting their intake at meals. Don't just write "Ate well" or "Ate poorly". Some places have a chart with percentages and examples of how to determine those so you can chart more precisely the amount the patient or resident ate. (25%, 50%, etc)

The only time we used colors, was with highlighters. Each shift was assigned a specific color (pink, green and blue) and the times for the treatments would be highlighted as well as the medications. It helped as a quick reference when flipping through the treatment books to be sure you caught everything to be done on your shift.

Check out Western Schools. They have a CEU course that is all about charting. You could also do a web search to find sites and info dedicated to this very topic that could show you different types of charting and what should and should not be included. Even samples of each.

For your own record, document everything. Buy a small notebook or tablet where you can write your own experiences and observations along with dates and times to have your own record at home. This is invaluable should any discrepancies occur or you get called into court to testify, etc.

Just my opinion.

meownsmile, BSN, RN · Oct 21, 2003

Black ink only where i work. I wish they would ban the gel ink for charting too because it smudges.

Hellllllo Nurse, BSN, RN · Oct 21, 2003

I've noticed (when working agency) that older nursing homes that don't have any computerization often require charting to be done in black by days, green for PMs and red for nocs.

Where I work now, charting is done in black, but noting orders is done in red ink.

Rustyhammer · Oct 21, 2003

The color differences used to be pretty common way back (like 10+ years ago). I haven't seen that method used in a long time.

Mostly I just see black ink in the charts.

Timing and dating is essential if for no other reason for your own protection.

-R