People choose to become nurses for many good reasons — and unfortunately, charting isn’t usually one of them! In fact, charting is often the least favorite part of the job for nurses. Nevertheless, providing the best possible patient care requires effective charting. With that in mind, here’s a quick look at why charting in nursing is so important, and some dos and don’ts for doing it successfully.
Why Is Charting in Nursing So Important?
So, what makes charting such an important part of nursing? As the process of taking notes and documenting updates on a patient’s condition, charting is the basis for quality care. When you chart well, you let other caregivers know what needs to be done with each patient, at any given time.
Yes, many nurses find charting to be tedious. But make no mistake — effective charting helps prevent errors, helps recover from quickly from illness and injury more quickly, and helps keep patients safe and healthy in general. Above all else, who’s more in tune with a patient’s day-to-day status than their bedside nurse?
In addition, accurate charting in nursing also helps protect you (and the facility you work in) from legal risk or insurance denials.
Effective charting can also make a big difference in how well you perform in your job. Therefore, being good at charting can be a key skill for advancing your career and even increasing your pay!
Charting in Nursing: 10 Dos and Don’ts
Yet many nurses struggle with charting, and that’s understandable. Many people become nurses because they want to deliver hands-on care. Even if you love charting and do it well, you might want to consider double-checking your skills. Taking time to write careful notes can seem like a different kind of work, especially when it has to be done carefully.
So, to help you overcome any difficulties you may have with this important task, here’s a rundown of what to do (and what to avoid doing) when charting in nursing.
#1: Don’t Use Abbreviations That Others Won’t Understand
Effective charting in nursing requires being as clear and consistent as possible. Abbreviations that are hard for others to understand can easily lead to error. Taking a little extra time to spell things out carefully helps ensure that you’re not causing any harmful mistakes.
#2: Do Write Clearly and Legibly
Another common source of error is good old-fashioned sloppy handwriting. It’s important to make sure your notes can be understood. When you’re writing, ask yourself if you’ll be able to understand it later on. If you can’t, other nurses and clinicians probably won’t be able to, either.
#3: Don’t Use Terms on The Joint Commission’s “Do Not Use” List
The Joint Commission created a list of “do not use” terms to help make it absolutely clear what to avoid writing when charting in nursing.
Some of them are a little tricky. For instance, you should always write out “morphine sulfate” and “magnesium sulfate.” Why? Because their abbreviations, MgSO4 and MSO4, are too often mistaken for one another. And that can cause serious problems when it comes to prescribing medications.
The good news is that the list is relatively short. We recommend taking the time to review it and commit it to memory. You can find a copy here.
#4: Do Memorize the SOAP Technique
You probably learned the SOAP technique in nursing school. A clinical method for taking the most accurate notes possible, SOAP breaks charting into four different steps:
- Subjective info, which is a list of what the patient has said about their symptoms, feelings, or the events they’ve undergone, as well as comments from family, witnesses or doctors
- Objective info, which is documentation of actual real events in their history, including physical exams and lab results
- Assessment, or interpretations of the patient’s condition, especially recent changes or new symptoms
- Planning, or actions to take, such as blood tests or recommended medications
This is, of course, a very basic summary of the SOAP technique. You can find a more detailed description here.
#5: Don’t Pre-chart
Pre-charting is another common source of error and wasted time. What may seem like a way to get the job done faster too often just causes extra work. For instance, when you chart ahead of time, you may not have time later to correct information that’s changed over the course of your shift.
#6: Do Take Advantage of Technology
We know technology can be confusing, especially with so many new innovations (such as healthcare AI) in virtually every setting. But technology is also extremely useful!
For instance, charting can be done much faster and more accurately on a keyboard than by hand. And because so much of charting in nursing means working with different EMRs and flow sheets, it’s best to get familiar with this tech. Knowing how to validate automatic EMR records, rather than making separate notes, can save you serious time. It’ll also help you avoid the common error of double-documenting.
#7: Don’t Practice “Double-documentation”
Double documentation means taking notes in narrative form that are already captured in EMR flowsheets and data sets. It’s tempting to do this, and it may even seem helpful. But what you’re really doing is adding more clutter for others to sort through, and maybe even contradicting EMR data.
#8: Do Think of Others When Charting in Nursing
The best way to take helpful notes is to think of others who are also helping care for your patients. Is your charting accurate enough for them to act upon? Did you base it on observed fact, instead of opinion? Is your handwriting easy to read?
Having trouble with this one? Just think about all the times when you wished a nurse had been clearer in their notes. Then, then think of how you avoid those same mistakes!
#9: Don’t “Batch Chart”
It might be tempting to wait and do your charting in batches. But it’s always better to do it in real-time, if possible. “Batch charting” in nursing usually ends up taking longer. It can also lead to forgetting or leaving out something important. Waiting to make an important note could also make a big difference for a patient who’s in danger of decline and in need of rapid response.
Pro Tip: Pressed for time? Carry a notebook to take quick notes for charting later!
#10: Do Protect Patient Privacy When Charting in Nursing
Whether you’re officially adding to a patient’s chart or taking quick notes, remember to always stay HIPAA compliant! The law that forbids sharing private patient info, HIPAA, is taken very seriously in most facilities. Even notes jotted down while you make your rounds must be HIPAA compliant. So, make sure to keep those notes in a safe place. Additionally, always use bed or room numbers instead of a patient’s name.
Develop Your Charting Skills and More with CareerStaff
We hope you’ve found this rundown of dos and don’ts for charting in nursing helpful. Here at CareerStaff, we work to help nurses excel at their jobs, and to discover the best possible career opportunities. If you’re looking for some career guidance, or a new nursing job, we can help! Fill out a quick online application to get in touch with one of our award-winning nursing recruiters today.