When you’re still in nursing school, everything about the job seems neat and orderly — and there isn’t much real-world experience when it comes to one hugely important aspect of the job: charting.
Taking patient information down correctly is essential to avoid serious medical mistakes and legal issues. However, you can reduce the chances that you’ll make a mistake if you get into a routine and try to stick with it every time you go through a charting process.
Here are some of the top things you should be doing every time you chart:
1. Check the chart against the patient
When your shift is busy and you’re handling a full load of patients, it’s easy to mistakenly grab the wrong chart. Before you enter any information, verify the patient’s name and identifying information against the chart.
2. Never enter information prematurely
“Pre-charting” can be tempting because it can save time. However, if something changes at the last minute or there’s an unexpected event, you’ll be left trying to make an explanation you don’t want to have to make to your superiors. Do all your documentation in real time.
3. Ask for clarification
If you don’t understand the instructions you are given, don’t guess. Never accept an order that is unclear, contains abbreviations that could be interpreted more than one way, has illegible information or doesn’t seem to make sense.
4. If the patient says it, write it down
There’s no such thing as too much information on a medical chart. If a patient gives you some insignificant-seeming medical detail, write it down anyhow. You never know what may turn out to be important down the line.
5. If you do it, write it down
No matter how small the care, document it. For example, you might think a simple dressing change doesn’t really matter if you forget to document it. If that wound starts to drain rapidly, however, the number of dressing changes that have been done could indicate that the patient is getting worse. If you forget to document some, the next shift will have no idea there’s a problem.
If your license is called into question over a charting mistake, don’t hesitate to seek assistance with your professional license hearing.