The Nurse's Guide to Charting Efficiently
Brady Pregerson, MD & Rebekah Child | Scrubs Magazine
Despite a wealth of technological advances, we all still spend more time charting than we’d like. But what if you looked at charting as something other than a chore?
Instead of seeing it as one more thing to cross off your to-do list, what if you considered it a vital means of communication? After all, isn’t that the original purpose of charting?
Part I: Communicate With Other Nurses
In the first part of this four-part series, Dr. Brady and Nurse Rebekah explain what conspiring has to do with charting—and show you how conspiring with your colleagues can keep you out of court.
Dr. Brady: No, I’m not planning on writing a book called The ER Conspiracy. The books I write are actually all about doing your job better. In fact, by “conspire” I don’t mean the first definition in Merriam-Webster’s dictionary, which is to scheme or plot, but rather the second, which is more true to the verb’s etymology: from the Anglo-French conspirer, from the Latin conspirare, to be in harmony; conspire, from con = together + spirare = to breathe. The second definition is “To act in harmony toward a common end.” People, I just want us all to be in harmony and “breathe together.”
In medicine, we need to conspire or collaborate more. When different healthcare providers act together in harmony, patients will more likely be satisfied, rather than confused—and if something goes wrong and we all end up in court together, we’ll be less likely to have helped the plaintiff’s attorney.
Why will patients be more satisfied? The reason is simple. If everyone tells a patient something different, she doesn’t know whom to trust and gets confused.
Here’s an example:
A patient comes in with cough and shortness of breath. The ER nurse does her assessment and tells the patient it’s probably a virus, but that she needs a chest x-ray to be sure. Then the ER doctor comes in, does her assessment and tells the patient it’s probably a virus and she doesn’t need a chest x-ray or any antibiotics.
Two days later, she’s not better and goes to her doctor, who tells her she has bronchitis but doesn’t need an x-ray, and writes her a prescription for antibiotics. If she’s in the top fifth percentile for IQ, she’ll probably realize that differences of opinion are not uncommon in certain conditions. If she’s like the other 95 percent of your patients, she’ll probably be confused and assume that two of the three people who gave her advice are incompetent. If only everyone had acted in harmony, the patient might have instead been satisfied and content while the virus ran its course and she recovered completely.