Most nurses will tell you that they became a nurse because they wanted to care for people who are sick or injured. Or they want to help mothers safely welcome their babies into the world.
Nursing is also an intellectually challenging, fast-paced career that is constantly testing you.
And let’s not forget good salaries.
You probably won’t (ever) hear someone say they became a nurse because they wanted to do lots and lots of paperwork.
Charting and documentation.
It can be a grind and it’s a time-eater. A number of studies found that nurses spend between 19% to 35% of their working time documenting care. That’s a large chunk of their day that, instead of focusing on their patients, they have to spend on paperwork and entering data into the computer.
But it’s essential, and you know this because:
- Charts are the medical history book of your patients. It’s a record of every pill taken, injury and medical procedure given.
- Your patient’s health and medical outcome depends on their chart. If they take a bad turn, charts are going to help determine what went wrong and what needs to be changed.
- Charts are legal documents. If there’s a malpractice suit, the charts are going to be what are questioned in court.
Yes you know charting is important – and that you spend too much time on it. So we’ve gathered the top 10 charting tips from nurses across the county to help you chart more efficiently, professionally and most importantly – quickly.
10 Top Charting Tips:
- Put On Your Lawyer Cap
Charts are considered legal documents in a court of law. Treat them that way. Be precise, clear and professional.
- Get To The Point
Document only necessary facts, figures, observations and conversations. Don’t re-write War and Peace. Keep it short and to the point.
- Just The Facts
When you’re charting, stick to the facts and keep emotions out of it. When you have a difficult patient, simply record what happened, no matter how many curse words they threw at you.
- Create A System
Create your own assessment routine and charting system. Have a head to toe checklist to help you remember everything. A charting routine will cut down on time and reduce errors.
- Watch Your Abbreviations
Don’t make up your own abbreviations or use ones that aren’t approved by your healthcare institution.
- Write Legibly
No one wants to decipher your chicken scratch. If you’ve got bad handwriting, sometimes you may not even be able to read what you wrote. Keep it clean and legible.
- Chart As You Go
Chart in real time. Give your patients your full attention, but as soon as you’re finished with your assessment, go ahead and document.
- Note The Time
Anytime you make a notation – add the time. When you get busy, it’s easy to forget when you did something.
- Document Everything
Any important information, observations, conversations with patients, doctors or family members has to be included in your chart. No matter how insignificant it may seem, note it.
- Review Regularly
When you have a free minute whether it’s after an assessment or at the end of the day, take some time to review your charts. It’s a great way to catch any unseen errors.
- Use the computer documentation to cross-check times if you forget
- Do NOT erase on or alter charts
- Hone your typing skills to improve speed and accuracy with typing games
- Pay attention to the details
- If you have a concern about your patient, tell someone. Don’t assume the doctor reading the chart will automatically pick it up.
Good charting isn’t just about good handwriting and a CYA for any legal problems. A precise, accurate chart can make all the difference in your patient’s recovery.
Use these tips and not only will you be charting like a pro – you’ll be doing it in less time.
Want to share some charting tips of your own? Join us at The Buzz, our online community, and connect with fellow nurses who are just as passionate as you.
You can also check out NurseHivePrep.com for vital nursing news, education, resources and more.