The Nurse's Guide to Charting Efficiently
Brady Pregerson, MD & Rebekah Child | Scrubs Magazine
Nurse Rebekah: Most of us want to be the expert at something in our lives. Some people just pretend like they’re experts on everything—which we all know is totally implausible. (My hubby calls these people “Mr. SMITH,” which stands for Smartest Man In The Hemisphere. Try that on your next know-it-all…it’s hilarious.) But many people spend the majority of their lives honing their craft, knowledge and career. Whether you’re a working nurse or doctor, a Starbucks employee or an electrician, at some point you’ll probably know more than other people who may or may not be in your field, and your advice will be sought out. Therefore, because people are seeking your advice, you should make sure you know what you’re talking about—and if you DON’T know what you’re talking about, heed my mother’s advice to “keep your pie hole shut.”
I say this because patients look to us for guidance about their health. Sure, they may have had a prior appointment with Dr. Google, but they’re looking for your professional opinion. Stick to the facts. Using Dr. Brady’s example, I might say, “Mrs. Smith, because of your cough and fever, I’m going to order a chest x-ray per our protocol to expedite your care in the emergency room. The doctor will look at it and tell you what he thinks.” Leave it at that. Don’t claim virus or bacteria—because unless you brought your microscope with you, you won’t be able to defend that claim. And the physician should have the foresight to look in the chart and not say, “Oh, I don’t need a chest x-ray…why did that silly nurse order that?” Don’t staff-split. Leave that to the psych patients and four-year-olds.
Starting to get the idea? Only say—and write—exactly what you observe. Anything more is just speculation and can confuse and frustrate both patients and staff. Part II of the Charting Conspiracy series underlines the importance of effectively communicating your observations and concerns.