Nursing Edition: Tips for Charting!

June 4, 2018

Lately, I am more active on my Instagram stories with my work days and a lot of you have reached out that you would like some tips on charting. Charting is a daunting task; It seems as though there is so much to do, and it never ends. I am hoping that this post can help some of you improve your charting.

Charting is one of those skills, that like anything else, gets better with time/practice. For me, I feel like my charting improved when I began to organize my day better. Plus a good report sheet helps too!

My number one tip is to chart as much as you can in real time. I understand that some days are busy and this is completely unrealistic. I get that, but your charting is going to be significantly more accurate and concise when it is accomplished in real time.

When I cannot get to my chart, I write down everything on my time-sheet or on the back of my report sheet. Really, whatever paper is around me that I can keep for later. It works for an in-the-moment time crunch, but at the end of the day, I am scrambling to figure out what I have or have not charted. Often times I walk away at the end of the day wondering if I truly charted everything.

Secondly, make sure to chart every conversation you had with a provider throughout the day. It is important to keep track of these exchanges in the rare chance your patient's condition changes and the blame comes back to you. Your charting is not only your record of interventions and actions you perform throughout the day, but it is also a legal document. Remember to protect your license, after all, you worked hard for it! 

Lastly, review your charting at the end of the shift. It is easy to overlook stuff when you are racing to finish while your patient just hit the call light for the thousand time that day. Most of the time I do not find any gaps, but every rare moment I might have missed a dressing change or end time for an antibiotic. Always better to be safe than sorry.

Hope this helps!

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