Nurse Charting Tips and Tricks to Nailing Patient Charting
Charting in nursing provides a documented medical record of services provided during a patient’s care, including procedures performed, medications administered, diagnostic test results and interactions between the patient and healthcare professionals. Nurses have a tremendous responsibility to accurately complete patient charting, which is vital in preventing medical errors, delivering high-quality patient care and protecting medical staff from liability and malpractice claims.
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5 tips for charting in nursing
Ensure your patient documentation is as accurate, useful and completed in a timely manner with these five helpful nurse charting tips.
1. Find balance
“Nurses are taught to live by the credo ‘If it wasn’t charted, it wasn’t done,’” says Catherine Burger, RN, BS, MSOL, NEA-BC. “That said, nurses must balance the requirement of charting care provided with actual face-to-face time with the patients. In the age of the electronic medical record (EMR), nurses who are able to integrate technology at the bedside will find an efficient flow to documentation and patient interaction.”
2. Use technology to the fullest
Burger emphasizes the importance of nurses learning to use the EMR to their advantage when completing their nursing chart. “Many EMRs are designed to list body systems in a specific order, with a ‘Within Normal Limits’ as the default. If the nurse’s assessment of the patient is normal, except for lung sounds, the nurse should note abnormal lung sounds and just ‘validate’ that the remaining exam is within normal limits.”
3. Avoid double-documenting
Burger also points out that some seasoned nurses have a difficult time giving up the “play-by-play narrative note.” She explains that “with the design and functionality of the EMR, most information is contained in flowsheets and data sets. Nurses should refrain from wasting time double-documenting in a narrative and the flowsheets. Nurses should use a narrative note only when needing to tell the story of a patient event or when there is a designated shift summary link for the care team.”
4. Document in real time
“Nurses should strive to document in real time as opposed to batching their documentation,” warns Burger. “Studies have shown that it takes longer to batch-chart than it takes to document the care at the point of service. Another important reason to document in real time is the ability of many EMRs to use predictability models in the programming that actually alert the nurse, or rapid response team, that the patient is declining or expected to decline.”
5. Avoid pre-charting
The busier you are, the harder it is to keep your nursing charts updated, which is when errors and omissions are more likely to occur, reports the Denver College of Nursing. This is also when it’s most crucial to carefully document your actions. However, never chart in advance. Wait until tasks are completed to avoid potentially serious repercussions.