Make sure your writing is legible and not just to you but to everyone else. In the age of EMRs, this is becoming less and less of an issue, but there are still documents nurses have to fill out that’s not electronic.
When you’re documenting inpatient health records, you’re only charting the facts and nothing else. Avoid adding opinions or emotions in patient files. This can be easier said than done, especially if you’ve had an emotional interaction with the said patient or family members. This tip is especially important for ER nurses and mental health nurses who deal with patient interactions that can become emotionally charged. Pro Tip:Remember to think about how would your note look and sound to an outside person if it was to go before a courtroom.
With how busy you’re going to get, your going to be tempted to want to chart ahead time. Don’t do it. Just don’t. First of all, if you’re using an electronic medical record (EMR) many will time stamp what time you entered the information regardless of when you’re saying you actually did it. Plus, when you chart ahead of time you’re going to forget to change something at some point. Either you ended up not doing something you documented you’re going to do, or you fail to go back and document findings if it ends up not going as planned.
I mentioned above that your goal should be to chart in real-time. Unfortunately, you’re not always going to get a chance. For that reason, you need to keep scratch paper or “your brain” handy to take notes so you can chart them as soon as you get a chance. Different nurses have their ways of jotting down notes, so try asking other nurses how they take notes. Personally, for me, I carry “my brain” and a separate sheet of scratch paper in a foldable clipboard (Amazon link) similar to this one: I like it because I can fold it and put it in my side scrub leg pants. Another tip worth mentioning is if you’re jotting down notes is to buy your own pen. I recommend this for several reasons:
I know. I know. This is another chart in real-time vs batch documentation debate. From my experience charting in real-time is easier and decreases your chances of making mistakes. On paper, it seems like batch charting would be quicker. (You would go and do everything you need to do on all your patients and then sit down and chart everything on every patient at once.) The issue is trying to keep everything straight. Part of the problem is that it’s never as easy as you think it’s going to be. Between doctors, call-lights, and everything else, you might have good intentions but then realize at the end of your 12-hour shift that you haven’t charted hardly anything. When you finally do sit down to chart, you’ll spend so much time trying to figure out…
If there’s one thing that’s going to hang you out to dry, is charting that’s inconsistent. That’s part of the reason why if possible avoid double charting because it increases the chances you’re going to have inconsistent charting. An example of inconsistent patient charting would be charting in the flowsheets that the patient’s lung sounds were clear and then in your nursing note for the same assessment time charting coarse crackles as lung sounds.
There’s enough double charting we’re required to do. What we don’t want to do is create more double charting work for us. For example, if you’re charting system is electronic many of them have flowsheets. Your electronic charting system might call it something different. Regardless the main point is if you’ve charted something in another area of the chart, don’t bother mentioning it in your narrative note unless there’s a picture or context you’re trying to paint. An example of double charting would be charting 100% for meals (dinner) in the I/O flowsheets and than charting patient ate all of their dinner in the narrative notes.
Whenever I’m charting and struggling to figure out how much information to write or what to include I ask myself if this went to court what would they want to know. There are no assumptions being made in court and as I’ve already stated many times, the cases are going to happen so many years after our interaction with the patient that your charting will be the only reliable way you’re going to remember the care you provided.
When charting try to be concise as much as possible. Details given should be pertinent and have a point for putting it into the notes. I should mention that there are situations that might require more context than others (and honestly, knowing the difference usually comes with time), but do remember you’re writing notes, not novels.
While preparing for tests is important, what really matters is to understand how you will use the information once you’re working as a registered nurse. Put the concepts in the framework of the nursing process, says Angela Beck RN, MSN-Ed, a CAS Manager on Chamberlain’s Las Vegas campus. “Keeping these processes in mind while reading chapters is a way to actively read and study,” she said. “This will help you establish concrete memories of the standards for patient care and critically think about the concepts being taught.”