How well do you chart? Read the following to determine your level of mastery,
Level One: Novice
Your charting is neat and thorough. In addition to checking all the boxes on your computerized chart, you add the occasional brief note when the patient’s condition changes or you’ve had to convey a panic test result to the doctor. You never, ever double-chart.
Level Two: Experienced Novice
You’ve gone beyond simple notes. Now you’re writing in Nurse Code, using phrases like “complex medical history” or “interesting patient” with some frequency. You’ve learned that trigger phrases like that can warn anybody reading your notes that some of your patients have been interesting, with challenging diagnoses.
Level Three: Losing Your Religion
You begin to use the word “states” more often, as in “Patient states he sees small purple hippopotami at the end of his bed.” Your notes contain references to yourself in the third person, such as “This nurse then removed the patient’s hands from around her neck.”
Level Four: After You’ve Been Audited
All the extra stuff disappears and you’re back to Level One charting, fearful that you’ll have to meet with your boss again. The word “editorialize” may or may not have been used during that meeting.
Level Five: Approaching Mastery
Nurse Code makes a reappearance, but in veiled ways. The word “see” suddenly becomes much more useful, as in “see allergy list, pages 7 through 60” or “see q5 minute vital sign records.”
Level Six: Mastery Unlocked
You no longer care about double-charting if the situation warrants it. You occasionally write novels, especially if you have one of Those Patients. If you do, no detail is too small to include: “Patient states he is allergic to oxygen. Patient noted to be breathing comfortably on room air.” You’ve learned how to add notes to flowsheets, and where and when you can safely say the words “interesting history.” Your boss no longer reads your notes, as the thrill is gone. The other nurses you work with, though, smile and wink at you when they pick up your patients.