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01.02 Daily Charting

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Overview

  1. Importance of charting
    1. “If you did not chart it, it did not happen”
    2. Record of all medical care
    3. Guides future treatment
    4. Provides information for legal event

Nursing Points

General

  1. Components of charting
    1. Objectivity
      1. Avoid subjective information
      2. Only document what you
        1. See
        2. Hear
        3. Feel
      3. Use quotes if patient states something
    2. Legibility
      1. Handwritten charting
    3. Accuracy
      1. Document the truth
      2. Documenting dishonestly
        1. Fraudulent
        2. Loss of license
    4. Timeliness
      1. Do not chart in advance

Assessment

  1. Do’s and dont’s of charting
    1. Do
      1. Report critical values
      2. Use blue or black ink
      3. Be concise
    2. Don’t
      1. State your opinion
      2. Alter a chart
      3. Write a novel

Therapeutic Management

  1. Charting considerations
    1. Know approved abbreviations
    2. Understand your charting system
    3. Pay extra attention when rushed

Nursing Concepts

  1. Clinical judgement
  2. Communication
  3. Ethical and legal practice
  4. Safety

Reference Links

Study Tools

Video Transcript

Hi guys!  Today I want to take a minute to talk to about the daily charting that we do as nurses.  Although providing care to our patients is the most important part of our jobs its the charting which is the proof that we have done what is ordered and necessary in providing care.


Ok guys so lets start by talking about why charting is so important??  Well when you think about it charting is how we communicate with all the team members who are involved in the care of a single patient.  So true you will give report to the nurse following you but what about the other providers who are caring for the patient…they will be looking to the chart to learn the most they can about the patient which will really help others to guide the future treatment of the patient.  And although we really do not like to talk about this the chart will provide information if there unfortunately ever a legal event occurs. Guys can you imagine being asked a question about a patient you took care of 3 years ago? I don’t know about you but I have a hard time remembering my patients from last week!  So yes great charting is super important in this instance and with that I will say you may have already heard this saying but in regards to charting….”if you did not chart it, it did not happen.”

Let’s take a look at some of the most important components of charting.  First, objectivity…guys avoid subjective information or information based on your own feelings or opinions.  Statements in a chart should be objective or represent facts meaning only document what you see, hear, or feel.  Guys if your patient tells you something that you feel is important to chart you should document this statement in quotes.  Next is legibility so I know that most institutions use electronic medical charting or in other words, the computer to document but there always will be instances where you will have to write something instead of type.  Be sure your writing is legible, there shouldn’t be any doubt to what that writing says. Next guys is accuracy only document the truth, documenting dishonestly for whatever reason is 100% fraudulent which could lead to the loss of your license!  Finally, timely charting is super important meaning do not chart in advance. Now I know that as nurses we are always pressed for time and things come up that are out of our control….it is always better to document after the fact than before. So there was just a situation where I work that a surgery nurse documented or precharted to save time….there was a legal issue that came up with the case and after the lawyers gained access to the chart the first thing they questioned was the fact that the nurse clearly documented everything before they actually occurred which hence made the nurse lose all credibility.  So moral of the story is do not pre chart because it can only get you in trouble!

Ok lets take a look at a few more of the do’s and don’ts of charting.  Do report critical values and document that they were in fact reported.  If you have to write anything included in the patient’s permanent chart only use blue or black ink.  Guys do be concise, it is not necessary or beneficial to write a novel. As I mentioned before do not state your opinion only facts.  And probably the most important statement on this slide is absolutely never, ever alter a chart! You can absolutely lose your job and your nursing license which you worked so hard for if you were to do something like this!

A few final considerations be sure you know which abbreviations are approved when charting.  Guys since I started my nursing career 10 years ago there have been abbreviations that have changed so keep this in mind.  Make sure you understand the charting system that your place of employment uses. Since starting my nursing career I have used multiple charting systems with each having different requirements so my advice to you with this is to make sure you are appropriately trained and you are aware of the intricacies and requirements placed by your institution.  Finally, guys, when you are rushed these, are the times when mistakes or shortcuts are made with charting so in these instances take a deep breath and pay extra attention when you are feeling rushed.

Lets review!  The importance of charting is recording all medical care, guides future decisions, provides info in the event of a legal event.  The components of daily charting include objectivity, legibility, accuracy, and timeliness. Do be concise, use blue/black ink, and report critical values.  Don’t state your opinion or alter a chart. Be sure to know your facility’s charting system, approved abbreviations, and pay special attention when hurried.

A few nursing concepts that we can apply to daily charting are communication as this is one of the reasons we chart, clinical judgment as charting information can guide this, and ethical and legal practice as charting is always utilized in the event of a legal case.

We love you guys! Go out and be your best self today! And as always, Happy Nursing!

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