Tips for Patient Charting

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Accurate and concise patient charting is an important part of a nurse’s job. Through charting, nurses communicate vital information to the entire healthcare team. A patient chart is also a legal document that describes all aspects of a patient’s care, including medications administered, services provided and procedures performed.

Because the charting process is so essential, nurses should take the time to accurately and concisely document patient care before moving on to the next patient.

Many healthcare providers understand how time-consuming patient charting can be, and so many are moving toward implementing and refining Electronic Health Records (EHRs) to help streamline the process. Among the proponents is HCA Healthcare, a network of 185 hospitals and 119 freestanding surgery centers in the U.S. and the U.K.

As Sarah Michel, MBA, BSN, RN, NE-BC, director of nursing Innovation at HCA, told MEDITECH, “we recently implemented a redesigned EHR system across 170 facilities in 20 states, following an evidence-based design that aligns minimum documentation requirements with ideal workflow. As a result, we’ve saved up to two hours spent on documentation per nurse, per shift.”

Even nurses who work for providers with less advanced technology can take a page from HCA’s approach by using standardized terminology in their charting, and by using evidence-based nursing care plans.

These nurse charting tips can help save time and improve patient outcomes:

Use Evidence-Based Care Plans

The use of care plans encourages good documentation practices and provide a continuity of care across healthcare teams. As RN Central, an information and education portal for prospective nurses, explains, care plans specifically, “outline which observations to make, what nursing actions to carry out, and what instructions the client or family members require.”

 Document Patient Care Using Standard Medical Terminology

The use of standard terminology helps healthcare teams communicate accurately and appropriately with one another. Using standardized terminology in a patient’s chart also reduces the risk of medical error.

“Nurses from different units, hospitals, geographic areas, or countries will be able to use commonly understood terminology to identify the specific problem or intervention implied and the outcome observed,” Marjorie A. Rutherford, RN, MA, explained in the Online Journal of Issues in Nursing.

 Avoid Using Restricted Abbreviations in Patient Charting

The use of abbreviations in patient charting has been found to lead to medical error. As such, all healthcare providers should familiarize themselves with the Joint Commission’s “Do Not Use” list of abbreviations, and use this list religiously.

The “Do Not Use” list was developed to help prevent medical error by avoiding common misunderstandings and misinterpretations when reading a patient’s chart. When following these guidelines, nurses are prompted to write complete words, rather than abbreviations. For example, using “unit” instead of “u.”

Save Time by Integrating Technology

The widespread use of EHRs has revolutionized patient charting. Nurses can save time and improve charting accuracy by using their EHRs at a patient’s bedside and documenting observations, the administration of medication and practices performed in real time. The effective use of EHRs in charting can also improve communication between team members, helping nursing teams save time and avoid mistakes.

Use the HER’s Dictation Functionality

The dictation functionality included in many EHRs enable healthcare professionals to record their notes by speaking. This is one way that nurses can save time while recording pertinent details while at the patient’s bedside. When using dictation in the medical chart, nurses should always review the information recorded to ensure accuracy.

Document to Medical Necessity

The medical chart is a record of care. As such, the chart should include all pertinent details from a nurse’s contact with the patient. This includes all care provided, including patient education and relevant family interactions. Everything should be documented to medical necessity in order to provide a thorough record of care.

Remember that Medical Charts are Legal Documents

At the end of the day, the medical chart is a legal document. The medical chart can be a resource in payment disputes and in medical malpractice lawsuits. For this reason, nurses should always be objective, accurate and clear when charting. Doing so will protect all members of the nursing team as well as the healthcare provider.

Avoid Common Mistakes

Nurses still charting on paper can avoid common mistakes by writing clearly and legibly, drawing lines through blank spaces, and documenting actions as they occur. Doing so will help save time in the long run, while also preventing costly mistakes.

About Duquesne University’s Online MSN Program

Duquesne University’s MSN degree program prepares RNs for careers in leadership and to set new standards of care. The university’s online MSN and Post-Master’s Certificate degree programs allow nurses to continue their careers and personal lives while earning an advanced education. The school offers programs in Family (Individual Across a Life Span) Nurse Practitioner, Forensic Nursing and Nursing Education and Faculty Role.

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How evidence-based clinical documentation gives time back to nurses: Meditech

What Is A Nursing Care Plan and Why is it Needed?:

Standardized Nursing Language: What Does It Mean for Nursing Practice?: OJIN

Do Not Use List: Joint Commission

The Impact of Abbreviations on Patient Safety: Joint Commission Journal

Reducing unsafe abbreviations: NCBI

8 common charting mistakes to avoid: NSO

Documentation: You’ve got a lot to lose: American Nurse Today

Nurse Charting: 7 Tips And Tricks That Will Make Your Life Easier: Onward Healthcare

Getting Your Notes Done on Time: FPM Journal