Charting and documentation guide for nursing studentsNovember 21, 2014
There is a lot to learn about patient care when you are in nursing school. In addition to understating various disease processes and learning how to perform certain procedures, you also calculate medication dosages and review test results. But there is another important aspect of nursing, you may not have thought about. Documentation and charting is an essential part of the job for all healthcare professionals including nurses and nursing students.
As a nursing student, it is best to learn the correct way of charting from the start. Getting into the right habits early in your nursing career, might save you from headaches later in your career.
The importance of charting for nurses
There is a saying in medicine “if you did not chart it, it did not happen.” The importance of good charting cannot be overstated. The information you document in the patient’s medical record serves several purposes.
The medical chart provides a record of everything that was done regarding the patient’s medical care. It includes information on medications, procedures, results of diagnostic tests and all interactions with doctors and other healthcare professionals. Past surgeries, medical conditions and hospitalization are also documented. Information in the chart helps other medical workers understand what is going on with the patient.
A medical chart also provides information in the event of legal action or concerns, which is another reason accurate documentation is so critical. Keep in mind, in most instances medical malpractice cases have a statute of limitation of two years to be filed. But the case may not get to trial until years later. The bottom line is, you may be called to court to discuss a medical case years after the event took place. Your charting will be what you rely on, not your memory of the events.
Components of charting for nurses
Whether you are a nursing student or an experienced nurse, there are several things to keep in mind when you are charting.
Avoid charting what someone else may have told you. Only document what you see, hear and feel. If you chart something the patient reports, be sure to indicate the patient is stating it, such as “patient stated he was not in any pain.”
If you are using a computer charting system, you will not have to worry about handwriting. But if you are documenting the old fashioned way, make sure your handwriting is legible.
Accuracy is one of the most important factors when it comes to charting. Even if you did the procedure correctly or gave the right dosage of medication, if you charted it incorrectly, it appears you did it wrong.
You may not always be able to, but try to chart as soon as possible after doing something. If you do have a late charting entry, follow hospital policies.
Know the abbreviation policy for your facility
Healthcare facilities may allow different abbreviations when charting. If an abbreviation is not approved, do not use it. Ask your nursing preceptor where you can find a list of acceptable abbreviations.
Make sure you understand how to use the charting system
If you are using computer charting, which more medical facilities are, make sure you have been trained. There are several different types of electronic medical record systems, which may be formatted differently.
Pay extra attention to charting when you feel rushed
If you are very busy and being pulled in different directions, you may be more likely to make charting errors. Take a step back and make sure you know what you are documenting.
Be sure you understand the charting policies for nursing students
Some facilities allow students to document just as a nurse does. After reviewing your charting, your nursing preceptor will co-sign. Policies may vary, so be sure to ask when you start a clinical rotation.
Realize things are done differently at different facilities
During nursing school, you will likely be attending clinical rotations at different facilities. One facility may have different procedures than another. Don’t assume charting practices are the same.
Do’s and don’ts of charting
- Do report critical values according to hospital policy
As a nursing student, you most likely will not be the person reporting critical values to the physician. But it is good to be aware, most hospitals have a protocol in place for reporting critical results.
- Do use blue or black ink
Hospital procedures may vary on which color of ink is acceptable. In most cases, if charting is handwritten, blue or black ink are the only colors allowed.
- Do be concise and to the point
Sum-up your information in a concise manner. Keep in mind, someone else reading wants to get to the point and find the information they need without sorting through irreverent notes.
- Don’t state your opinion
For example, your patient may be mean and rude, but it’s not a good idea to chart what a curmudgeon he or she is. Charting something like that would be an opinion, not fact.
- Don’t erase or alter a chart
Healthcare facilities have different practices for correcting charting and dealing with errors. Facilities do not allow you to erase charting in order to make corrections. In addition, do not alter a chart by removing documents or documenting something you did not do just to avoid getting in trouble. Altering or falsifying a medical chart is a criminal offense.
- Don’t chart ahead of time
You may know you are going to give a certain medication or do a procedure and want to get a jump on charting. But charting before you do something is never a good idea. Something can happen, which changes what you charted, and you will have to make corrections.
- Don’t write a novel
Although you want to be accurate and clear on your charting, you don’t need to go overboard and write a novel. You need to document enough information to explain a patient’s condition or treatment and paint a clear picture of what is going on with the patient.