Some nurses have a passion for serving their community. Others have a broad interest in the medical field and patient care. Some people find their way to nursing by chance, while others have always known it’s their ultimate life goal. So many reasons and circumstances can lead you into the exciting field of nursing—although charting may not be one of them.
Good documentation (Charting) is an essential (although sometimes exasperating) part of the job. But honing your charting skills can make all the difference in your patient’s care and the quality of your work.
This guide to nurse charting can help you improve your charting skills, so it becomes less of an inconvenience and more of an intuition.
What is Charting in Nursing?
Charting is as vital a skill to nursing as compassion, expertise, and experience. Charting is documentation of medical services, patient status, and more. It’s a living record of what’s going on with a patient and can include things like:
- Procedures performed
- Medications administered
- Diagnostic tests performed
- Test results
Basically, if it happens to a patient, it goes on the patient’s chart.
Why is Nursing Charting Important?
Nurses are a patient’s primary advocate. Thanks to frequent and extensive patient interactions, nurses tend to have the best understanding of their patients’ conditions and needs. However, when nurses don’t document critical patient information about their care or symptoms, there’s no way for other staff to be fully equipped to give that patient the best care.
Your nursing charts can affect everyone in your unit and beyond. If you’re looking for reasons to write good nursing notes, here are just a few:
- Other nurses on your team rely on the information you provide.
- Doctors and specialists use those progress notes to make medical assessments.
- Your charting eventually becomes part of your patient’s permanent medical record.
- Charting could be used for legal or insurance purposes down the line.
How Do You Write a Nursing Note?
The first step to understanding how to write nursing notes to conduct proper documentation is deciding which method works for you (or figuring out which version your facility uses). Proper nursing documentation examples always include a popular technique called the SOAP note, which includes four distinct sections:
- Subjective – This is a patient’s personal account of their injuries, symptoms, pain levels, and major concerns. It can also include any important information from family members or witnesses present.
- Objective – This applies to both qualitative and quantitative data collected from the patient’s physical assessment and lab results:
- Qualitative – Observable symptoms such as swelling, bruising, skin discoloration.
- Quantitative – Numerically recorded data such as heart rate and blood pressure.
- Assessment – Assessment is a general interpretation of the patient’s situation. This could include a wide range of relevant details like:
- The severity of the patient’s condition.
- Any changes since they first arrived, including new symptoms.
- If there’s enough available information, potential diagnosis.
- Plan – The plan section of your patient charting is where you’ll document what you’ll be doing to care for your patient. Proper nursing charting examples may include:
- Precautionary measures to take.
- Subsequent evaluations that need to be conducted, such as blood tests, CT scans, X-rays, etc.
- Medications prescribed on the patient’s medical record.
- Necessary procedures, such as surgery or blood transfusion.
- Follow-up assessments to be performed and when.
- What to be on the lookout for when checking on the patient.
Each section of SOAP has certain dos and don’ts, but overall, it’s crucial to include the correct information where it belongs to be sure your patient’s chart has a nursing care plan that works for them.
How Can Nurses Chart Better?
Learning how to chart is one thing. Charting well is another altogether. Here are a few tips and tricks that can improve your charting while also making it easier for you.
#1 Consistent Charting Techniques
Do you ever leave a note somewhere to remind your future self of something, but by the time you find the message, you can’t understand what your past self was trying to say? Is that 6 am or pm? And what does “MFLP” stand for?
Sticking with a consistent note or reminder system winds up saving your future self a lot of hassle—the same goes for your successful charting techniques.
The Joint Commission has specific policies on acceptable abbreviations and short-hand. They’ve even created an official “Do Not Use” list of potentially confusing or misinterpreted abbreviations, as well as proper terminology.
Using the wrong abbreviation doesn’t just create confusion and waste everyone’s time, but it can change your note’s meaning. A fellow nurse practitioner may misinterpret your seldom-used abbreviation as something else altogether and administer the wrong drug.
So spend a little time committing the Do Not Use List of terms to memory and refresh yourself now and again. You’ll save yourself, your team, and maybe even your patient a lot of confusion.
#2 Optimize Your Technology Use
Many hospitals have abandoned pen-and-paper documentation for a sleek and intuitive computerized charting system. There are plenty of benefits for going digital—it’s faster to type than write by hand, plus there’s less possibility that important details get lost in the translation of illegible doctor-scrawl.
However, if your hospital is transitioning to digital charting, here are a few ways to use all of technology’s offerings to your advantage:
- Master the keyboard shortcuts – Much like learning to type, learning keyboard shortcuts can be cumbersome at first. But keyboard shortcuts can actually save you precious time in your day. Soon after you start practicing, your fingers will be dexterously performing computer commands.
- Learn the lingo – Memorize your facility’s accepted abbreviations to avoid confusion, and reduce time spent spelling out the lengthy medical term or searching for the proper acronym.
- Work with flow sheets – Utilize (or create) standardized flow sheets that streamline your nursing process.
Despite all of the technological advantages of computer patient charting, be wary of copying and pasting. It can speed up the process, but forgetting to edit all of the necessary details and numbers (for example, test results or prescription doses) can have much more costly effects than the extra minute it would take to type it out again.
#3 It’s Always Better to Over-Chart than Under-Chart
The golden rule in nursing is that if it’s not in the chart, it didn’t happen.
You might automatically assume that everyone reading your chart has the same internal knowledge that you and your fellow nurses have. But remember, lawyers, insurance claims adjusters, and other third-parties may rely on your charting for critical decision-making. With no pre-existing understanding of your hospital’s policies and basic care provisions, the only proof they have is your meticulously maintained charts.
Here are a few specifics that you should always include on a patient’s chart, both for their safety and to avoid professional liability for negligence. This list is non-exhaustive, and you should always adhere to hospital protocols and best practices, but some of the most common charting slip-ups happen when you leave the following details out:
- Pre-existing medical conditions
- Current (or recent) medications
- Any known drug allergies
- All aspects of a patient’s treatment, with timestamps (changing bandages, irrigating wounds, rehabilitative exercises)
- Medications that have been administered
- Discontinuation of a medication or treatment
- Adverse reactions to a drug, even minor ones
- Changes to a patient’s overall health or condition, especially worsening
These requirements can seem like a lot, but all of these details are a vital part of the nursing process (no pun intended).
Of course, “over-charting” has its limits. Not everything needs extensive documentation. But if it’s important now or might be important later on, put it on the chart.
#4 Chart for Others, Not Just Yourself
You’re one of many nurses that a patient is likely to encounter during their stay in your ward. Once your shift comes to an end, someone else takes over. If that nurse can’t understand the notes you’ve left, how will they provide the best and safest care plan possible?
Your notes should include enough detail for the night shift nurses to understand everything they need to know from looking at the patient chart. It can be tricky to know exactly what to include, but you can rely on your own experience with other nurse’s charts to get a better idea.
Ask yourself the following questions to figure out how your charting should look:
- When you take over a patient at the beginning of the day, what do you wish your fellow nurses had included?
- Were they too vague regarding dosage, symptoms, or patient history?
- Do the notes seem overly subjective and intuitive rather than fact-based?
- Is the handwriting illegible, or are the abbreviations unclear?
You can learn from other nurses’ mistakes to provide your colleagues with a better class of charts. Soon enough, your charts will be the poster child for good nursing notes examples.
#5 Chart in Real-Time (Within Reason)
When you’re finishing up with a patient and hear shouting from down the hall, it’s probably not the best time to sit down and write a detailed account of your last blood draw. But when you have a spare few moments—which is, of course, a rare luxury in the life of a nurse practitioner—it’s best to jot down a few quick impressions and details rather than saving it all for the end of your shift.
But how do you do this when you hardly have a spare moment to think, let alone provide extensive medical documentation? Here are a couple of helpful tips for when you’re short on time:
- Carry a small notebook and retractable pen in your pocket to write important notes on the go. That way, when you complete your formal charting later, you won’t be scrambling to remember which patient needed what and when you last dispensed their medication. Remember that even personal notes should be HIPAA-compliant: use room numbers instead of names and shred your notes after documenting the details on their chart.
- Use an adapted version of charting by exception (CBE). Hospitals that operate under this model only chart things that seem abnormal, but the incompleteness of the patient chart can lead to mistakes that leave you vulnerable to legal liability and other patient safety risks.
However, this system can still be helpful with your own personal notes. If almost everything seems to be within normal limits (WNL), you can save time by jotting down the few concerning symptoms, like an elevated heart rate or mild stomach pain. That way, you’ll have an unofficial record of the most critical facts. Later, when you have a rare moment to breathe, you can fill in the more monotonous details.
Again, the patient in need comes first, but the notes you make (or forget to make) have about as much long-term impact as anything else you do during a shift.
Put Your Charting To Good Use With Host Healthcare
Charting is a crucial part of a nurse’s care—now, you can take those skills on the road and put them to good use in hospitals across the country as a travel nurse.
As a traveler, you’ll have access to a worldwide network of job opportunities, plus day one benefits, some of the highest pay in your industry, and a smooth transition thanks to our complimentary deluxe housing. The process couldn’t be more straightforward:
- Fill out a quick application
- Create a Host Healthcare profile
- Get connected to a top-notch recruiter
- Find the perfect job for you!