Charting the condition and treatment of patients is a fundamental part of being a nurse. You’ll spend a lot of time with your patients while the doctor is away, so you need to record every detail of their experience. Otherwise, important details could get lost in the shuffle and the patient’s condition could suffer as a result. Even worse, if you’re sloppy with your chart or use misleading language, you could be held legally responsible. When the stakes are this high, you can’t afford to make a mistake. Use these tips and tricks to learn how to chart like a pro without endangering you or your patients.
Stick to the Facts
It’s always best to stick to the facts when charting your interactions with patients. You should include all relevant information, including the condition of the patient, all treatments and medications given to the patient, as well as any supplemental information such as patient movement, behavior, and symptoms that might inform the doctor’s opinion.
While charting can encompass a wide variety of facts and details, record the details as they unfold in real-time. Be observant and don’t stray from what you see and hear. If something happened with the patient, but the details are fuzzy, try to remember the circumstances to the best of your abilities and only add information that you can observe with your own eyes.
State Your Concerns Clearly
Some nurses may be hesitant to express their concerns when charting a patient, especially if they’re unsure of themselves or their concerns seem relatively minor or unimportant and they don’t want to waste the doctor’s time. But this isn’t a successful approach to charting. If you are concerned about one of your patients, you need to pass those concerns along to the doctor. If you’re unsure of yourself, record the details as you see them and let the facts speak for themselves. Try not to push the doctor in any specific direction with your notes but present them with all the information they need to make an informed decision.
Avoid Using Subjective Language
As important as it is to state your concerns and include all supplemental information, no matter how insignificant it may seem, it’s best to avoid all subjective language in your report. Stay away from words and phrases that may be misinterpreted or that illustrate a clear bias. The details and facts should be enough to steer the doctor in the right direction. Write your report clearly and leave plenty of room for the doctor to come to their own conclusions. Remember that you could be penalized for omitting certain details because you have your own ideas of what’s going on with your patient. Stick to the facts and you’ll be fine every time.
As you gain more experience, charting will become just another routine part of the job. Over time, you’ll learn how to chart a patient without second guessing yourself. Be clear, thorough and succinct and you’ll do great.