Daily Charting

Let’s take a look at some of the most important components of charting.  First, objectivity…guys avoid subjective information or information based on your own feelings or opinions.  Statements in a chart should be objective or represent facts meaning only document what you see, hear, or feel.  Guys if your patient tells you something that you feel is important to chart you should document this statement in quotes.  Next is legibility so I know that most institutions use electronic medical charting or in other words, the computer to document but there always will be instances where you will have to write something instead of type.  Be sure your writing is legible, there shouldn’t be any doubt to what that writing says. Next guys is accuracy only document the truth, documenting dishonestly for whatever reason is 100% fraudulent which could lead to the loss of your license!  Finally, timely charting is super important meaning do not chart in advance. Now I know that as nurses we are always pressed for time and things come up that are out of our control….it is always better to document after the fact than before. So there was just a situation where I work that a surgery nurse documented or precharted to save time….there was a legal issue that came up with the case and after the lawyers gained access to the chart the first thing they questioned was the fact that the nurse clearly documented everything before they actually occurred which hence made the nurse lose all credibility.  So moral of the story is do not pre chart because it can only get you in trouble!