Reviewed by: Ashley Chancellor
Keeping accurate nursing documentation and nursing charts for your patients’ information ensures that you are taking the best possible care for both patients and clients. Read on to discover what nurse charting is, what it involves, the do’s and don’ts of nurse charting, and how advanced technology can help relieve some of the stress.
What is Charting in Nursing?
Patient charting is a necessary skill for nurses beyond nursing school. It is a living record of what’s going on with a patient and includes procedures performed, diagnostic tests performed, medication administered, and test results. A consistent form of documentation that everyone is familiar with allows each member of a health care team to have equal understanding of the treatment and progress of each patient at any point in time with less room for mistakes.
Why is Nursing Charting Important?
There is no doubt that being a healthcare provider in the nursing profession requires the ability to care for patients and document/communicate their treatments. No matter the setting, a nurse needs to properly document what they have done so that all medical personnel are aware of all interventions. Charting is an important documentation of who did what, when, and what the results were. Safekeeping of patient records and accurately completing necessary documentation with charting is vital in preventing medical errors and protects medical staff from liability and malpractice.
Below are the benefits of Nurse Charting:
- Ensures patient safety with thorough and complete documentation
- Keeps record of medicines and treatments given to patients
- Improves the quality of care provided by the hospital/clinic
- Allows for better communication with fellow healthcare providers and staff
- Reduces the chance for malpractice lawsuits
The importance of Nurse Charting is critical. It allows professionals to have a keepsake of records used as evidence in patient care, education, research, and legal proceedings. Having the awareness of what makes for successful charting and recognizing its value will benefit your career and help improve patients’ quality of life.
How Do You Write A Nursing Note?
Many nursing professionals use the SOAP method when writing a nursing note. How do you write one? Well, it includes four distinct sections.
Subjective: The “history” section. The patient’s personal account for their injuries which include symptoms, pain levels, and any major concerns.
- Name of patient
- Identifying data: Initials, age, race, gender, marital status
- All information the patient tells you
Objective: The physical exam and laboratory section. This includes qualitative and quantitative data collected from the patient’s physical assessment and labs.
- Vital signs including oxygen saturation when indicated
- Physical exam
- All labs, x-rays, etc. from the visit
Assessment: Your assessment of the patient’s problems. An interpretation of the patient’s situation. This includes any changes in the patient’s condition since they arrived, any new symptoms or severity of symptoms.
- Assessment: A description of the patient and the major problem in one sentence
- Try to take the assessment of the major problem to the highest level of diagnosis that you can
- Provide at least two different diagnosis for the major new problem identified in your note
Plan: Your plan for the patient based on the problem you’ve identified. This is where you plan the proper care for your patient. Some examples may include:
– Future tests to be done (blood, scans, X-rays, etc.)
– Medical record updates
– Follow-up assessments
– Make note of what to lookout for when checking in on the patient’s progress
How Can Nurses Chart Better?
Below are some tips on how you can enhance your documentation practices:
- Always double check the patient’s identifying information. Checking to confirm their name and date of birth are accurate is a simple yet crucial step that is easily overlooked. This will ensure accurate linking to his or her healthcare information records across all systems.
- Don’t wait until the end of the shift to document detailed notes. If you wait, you could forget to include crucial information.
- Remain objective in all documentation. Avoid documenting opinions or subjective conclusions about patients or colleagues in a patient’s chart.
- Make sure that all findings that are documented have been thoroughly communicated with the healthcare team and the patient and that both parties acknowledge the information being documented.
- Include documentation and verification that all delegated tasks have been completed by those under your direction or supervision.
- Correct any charting errors promptly in accordance with your facility’s policies and procedures.
How can an EHR help with nurse charting? An EHR (Electronic Health Record) is installed to ensure that nursing notes are complete and accurate. They have been widely adopted among many healthcare clinics in order to save staff time and reduce stress while improving patient care. Basically, using a digital record to maintain all patient charts is usually better for organization and retrieval of information for both the patient and the healthcare team. Although there is a widespread transition to digital systems, paper charting is still proving to be just as beneficial. Using both charting techniques together can also help promote continuity in patient care. If you are thinking about transitioning to the digital documenting world, continue on.
The Pros of Electronic Medical Records
- Standardized data
- Real-time data
- Enhanced patient privacy
The Cons of Electronic Medical Records
- Technology failures
- Does not fix all bad data
Electronic medical records aren’t going anywhere. It is more wise than not for healthcare facilities to have EHR plans in place, but should still utilize paper charting in the off-chance that digital systems could fall corrupt.
After discovering what nurse charting is, what it involves, the do’s and don’ts of nurse charting, and how advanced technology can help relieve some of the stress, we hope to have helped you gain a clearer understanding of the multitude of systems in place.
Step up your charting game and speak to one of our recruiters at MAS Medical Staffing about healthcare jobs today!
Ashley Chancellor, RN, Nurse Recruiter:
Ashley is a retired travel nurse with over 8 years of travel experience and 10yrs as an ICU nurse. After working through COVID she decided to take a much needed step away from bedside to explore other avenues and found herself on the recruiting side of things. Ashley is a transplant from Pittsburgh, PA to Tucson, AZ where she loves hiking, writing, traveling, fishing, cooking and cheering other nurses on as they go after their travel dreams!