Best Practices for Charting
Kathy Quan | NursingLink
Providing excellent patient care is the most important aspect of nursing. Moreover, taking credit for the care given is also an important responsibility. Most nurses hate the paperwork more than any other aspect of their job, but it’s critical that it be done, and be done well. As with every aspect of quality patient care, charting should be exceptional; it should never be taken lightly.
The chart is a legal medical record, communicating crucial information to other members of the health care team so that they can make informed decisions. An accurate chart is critical to assessing the patient’s health status, and determining future care and treatment methods.
State Facts, Not Opinions
One of the first lessons a nurse learns is that if she doesn’t chart something, it wasn’t done. As a nurse, you can argue to the death that you gave the right meds or checked the heart monitor, but if you neglected to chart it, there’s no legal record of it.
That doesn’t mean you should go chart-crazy, and jot down every minute detail. Stick to the facts! For example, don’t get caught in the habit of charting every two hours that a patient was “resting comfortably in bed” until you have actually checked on the patient and noted the exact time. And don’t get ahead of yourself: making a comment or checking off a box even two minutes in advance can come back to haunt you. If that patient falls, has a request that someone else responds to, or should code just a minute or two before your recorded entry, your whole level of care could come into question.
Your patient may be a mean, nasty, curmudgeon, but that’s not for you to say. Neither is it right to say she’s a sweet, adorable old lady. Look for the facts (signs, symptoms, and statements) as to the basis for the behavior. Is your patient in pain? Is he scared or fearful of a procedure or diagnosis? Is he depressed or anxious? Has he had some issues with family or caregivers? Is the sweet old lady being stoic? Does she understand her illness? Is she in denial? Or perhaps her symptoms have been well-controlled with the current medication regimen?
Patient A is experiencing 8/10 pain unrelieved by hydrocodone 500mg/5mg q 6 hours. Last dose given 1 hour ago. States he is in constant agony and exhibits angry behavior towards others.
Patient’s B’s wife confided that her husband is anxious about an upcoming lung biopsy and fears that he has cancer. His father had the same symptoms at his age and died from lung cancer.
Patient C states her pain is 0/10. States she hasn’t been pain-free in over a year now and is so grateful for her new care and treatment.
These are perfect examples of outstanding charting. Detailed and straightforward, these statements stick purely to observed behaviors, and medical facts, without any opinion or judgment stuck in.