Patient care involves many moving parts, especially in critical situations. Nurses must think on their feet, make quick decisions and be confident they are correct. Even in lower-stress provider-patient interactions, such as a routine checkup, certain steps are crucial to optimize patient care. One imperative process is charting.
Charting is a vital part of nursing education. Nurses pursuing higher education and opportunities to improve crucial skills like charting are well served in the online Registered Nurse (RN) to Bachelor of Science in Nursing (BSN) program from Northern Kentucky University (NKU).
What Is Charting and Why Is it so Important?
In simple terms, charting is the documentation necessary to record a patient’s status, medical services and more. It may include a patient’s test results, medication history, health history and any procedures they have undergone throughout their lifetime.
These data points help everyone attending to the patient provide the highest level of care. Other nurses, physicians and specialists rely on good charting to fully understand the patient’s needs. This information is essential when it comes to medication use. Many medications interact, so medical professionals must document every drug in the patient’s records.
In some cases, charting has legal or insurance purposes, providing even more incentive for nurses to be highly skilled in their documentation practices. The following are five tips on how nurses can make charting easier and better for patient outcomes overall:
- Consistency Is Key
Have you ever jotted down a note with a symbol or abbreviation to save time, only to forget what it signified when you needed it? Identifying a consistent charting system for your own purposes removes potential confusion when the information matters most.
Fortunately, nurses do have some guidance in this regard. The Joint Commission created a “Do Not Use” list that clarifies preferred abbreviations and terminology regarding medication-related documentation.
- Technology Is Your Friend
Some people prefer pen and paper. However, an increasing number of healthcare institutions are migrating to digital documentation, and nurses can use that to their advantage. Keyboard shortcuts expedite the charting process. Digital documentation also eliminates the potential for illegible penmanship. One word of caution is to avoid copying and pasting information. It might save time, but there’s also more room for error.
- When In Doubt, Over-Chart
You don’t want to be redundant, but you need to capture every piece of relevant information about the patient. Remember, not everyone is as intimately involved with your patient as you are. Lawyers, insurance adjusters and outside specialists assume everything they need to make decisions is in the chart. A rule of thumb is to include information that is important now or might be necessary for the future.
- Try to Chart in Real Time
Our memories inevitably fail us from time to time. Therefore, the sooner you can record patient details, the better. One suggestion is to use a voice memo to quickly record the most important information between patients. At the very least, carry a pen and small notebook to jot down highly pertinent information that may jog your memory when you can fully document.
- Keep It Neutral
As professionals in healthcare, nurses know they need an unbiased perspective. Yet, the compassion and advocacy aspect of patient care is also a strong motivator. Nurses can still do their job well without voicing a subjective opinion or speculative information via the patient’s chart. In fact, the best approach you can take for your patients is to be as objective and patient focused as possible.
Not All Charting Is Equal
There are many different “types” of charting, such as the following:
- Narrative notes
- Charting by exception (CBE)
- SOAP(IER) for subjective, objective, assessment, plan, intervention, evaluation and revision
- PIE for problems, interventions and evaluations
- Focus (DAR) for data, action and response
Each type of charting has its advantages and disadvantages. For example, CBE only documents factors outside the “norm.” But how can outside parties know what is normal for any individual patient? As a nurse, you may not get to choose which system you prefer if there’s a standard in place. The best course is to rise to an expert level of charting, no matter your assignment.
How an BSN Degree Can Help
Graduates of NKU’s online RN to BSN program have the skills and knowledge to serve patients best. From charting to note-taking to health information documentation, the program emphasizes the important elements of nursing that keep information organized.
Learn more about NKU’s online RN to BSN program.
