What should be included when Charting?

Midwest4me · Apr 9, 2009

Back when I attended nsg school we were taught SOAP charting(S= subjective, O= objective, A= assessment, P= plan). You NEVER got taught ANY tips on charting? I find that so very odd...and sad. Always CYA when you chart--so be thorough!

Nursebabe2009 · Apr 9, 2009

Thank you. We were told to chart everything.

madwife2002, BSN, RN · Apr 9, 2009

Yep chart everything, some places chart by exception which means anything abnormal. You can never document enough. I suggest when you have an interaction with pt you chart it-then if it ever goes to court you have proof of what you did. Trust me you will never remember what you did and when unless it is documented

meluhn · Apr 9, 2009

In LTC the charting is different than acute care. I don't think its feasible to just chart everything. Usually you are charting on only certain people for a specific reason, either because they are new admits, had an issue or a fall, or for medicare purposes. Your charting has to focus on these things. For example, if you are charting on a pt that had n/v, you would want to chart everything r/t a gi assessment plus appetite, temp, etc. If they had a fall you would assess them for injury and chart your assessment and whethter you noted any injury or not. For new admits, they probably get a full assessment for the 1st 5 days or so. For medicare, it is specific to why they are there. Check with your peceptor about the facility policy on this.

LPN&momof3 · Apr 9, 2009

I agree with meluhn and I would check with your facility policy on charting. Where I work we actually get in trouble for documenting too much. Like things that if the state found on their annual visit they could get trouble for.

CoffeeRTC, BSN, RN · Apr 9, 2009

Head over to the LTC forum for some support too.

Ask your Assessment Co-ordinator (care plan or MDS nurse) about this. I'm sure they will have a few cheat sheets to give you.

Most of what they do is based on the charting (or lack of) that the nurses do. This helps them complete assessments which will help with payment issues from certain insurances including Medicare.

In LTC charting is about CYA too.

mejia1381 · Apr 9, 2009

I believe that charting is very individualized. Some chart by exception and others chart everything. In my experience, having a combination of the two styles is best. Depending in the situation u may only have to chart by exception. For example, if you have a patient that is stable and not much going on then why chart everything? It takes up to much time. I am sure that your day is pretty busy! But, when you have a change in patient status then you may have to chart everything!!!

NeuroICURN · Apr 10, 2009

I agree with meluhn and I would check with your facility policy on charting. Where I work we actually get in trouble for documenting too much. Like things that if the state found on their annual visit they could get trouble for.

Just because they can get in trouble for it, doesn't mean it shouldn't be charted!! If you were actually told that...I would get the heck out of there!!

I agree that charting in a LTC facility and a hospital are very different, but that being said.....I chart so that if I get called into court 7 years from now, I can look back at my charting and tell you exactly what was going on with that patient. And as my instructors once drilled into my head........"If you don't chart it, it didn't happen".

Nursebabe2009 · Apr 10, 2009

Actually everyone that works there is very busy. It's understaffed. Everyone wants to get home early, and they don't have time to help. A shift that should end in eight hours usually ends in ten hours (or more).

meluhn · Apr 10, 2009

Maybe you could ask for someone's number and talk to them after hours about it when they could take their time and explain it to you. Be sure to take notes because there are specific guidelines.

NeuroICURN · Apr 10, 2009

BTW....why wasn't this addressed by your preceptor?

I know I read all the charting done by any orientee with me...then we sit and review what's right and wrong and she fixes what's wrong (thank goodness we have electronic charting). In the case of somewhere with paper charting....you probably should have done what I did in nursing school, which was write out my note on another piece of paper and have it reviewed before writing it. It would have taken a little longer, yes, but it would have saved a lot of headache now....agree?