Patient Charting and Health Information – Tips for Nurses

Patient care involves a lot of moving parts, especially in critical situations. Nurses must think on their feet, make quick decisions and be confident those decisions 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.

What Is Charting and Why Is It so Important?

In simple terms, charting is documentation to have a record of patient status, medical services and more. It may include test results, medication history, health history and any procedures the patient has undergone throughout their lifetime.

These data points allow everyone attending to the patient to 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 it’s vital that medical professionals document every drug in the patient’s records.

In some cases, charting has legal or insurance purposes which provides 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.

1) Consistency Is Key

Have you ever jotted down a note with a symbol or abbreviation to save time, only to not remember what it signified when you really 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 has created a “Do Not Use” list that clarifies which abbreviations and terminology they prefer regarding medication-related documentation.

2) 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: Avoid copying and pasting information. It might save time, but there’s also more room for error.

3) 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 that everything they need to make decisions is in the chart.

Rule of thumb: If information is important now, or might be necessary for the future, include it.

4) 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 sit down and document in full.

5) Keep It Neutral

As professionals in healthcare, nurses know they need to have 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:

• Narrative Notes
• Charting By Exception (CBE)
• SOAP(IER) for subjective, objective, assessment, plan, intervention, evaluation, revision
• PIE for problems, interventions, evaluations
• Focus (DAR) for data, action, response

Each type of charting has its advantages and disadvantages. For example, CBE only documents things that are 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.

The good news is, you don’t have to figure that all out on your own. Charting is a vital part of nursing education. Registered nurses (RNs) pursuing higher education with their Bachelor of Science in Nursing (BSN) degree have access to a fully holistic approach to the nursing profession. With a BSN, you’ll have the knowledge and skills to serve your patients in the best way possible.

Learn more about Mississippi College’s online RN to BSN program.