Documentation Pro Tips

In this lesson, we are going to look at some tips to help you document like a pro.

Even as experienced nurses, know that your documentation will never be flawless, and that’s totally ok. And if you make a mistake, there are ways to correct it. So, what happens if you write something incorrectly? You can’t use white out and you can’t delete documentation. Strike through the incorrect part, initial it and then write down the correct info. A “strike through” is a SINGLE line through words. It’s there so that they can see that there was an error, and what the previous error was.

What about if you forget to write something down? You can type or write “late entry”, put a time and date stamp of when it actually occurred, and then write your documentation. It shows that the care actually occurred.

Be sure to initial any areas that have to be corrected.

One thing to remember when you’re charting is that EVERYTHING gets watched. Your managers, upper level management…they can all see what records you access and when. So make sure that you’re only accessing the patients you’re caring for – just follow HIPAA.

Also, don’t be sloppy or lazy in your documentation. Don’t cut corners. Use the right abbreviations. It just sets you up to be called out.

Make sure that you follow your facility’s policy when documenting and make sure that you time stamp every entry. It’s all about covering your ass – or CYA as we like to say!

When we talk about nursing narrative or the nurse’s note, what are we talking about?

Well, it’s part of the documentation that talks about what the other areas of the chart won’t discuss. These are like patient statements or things you observe that you can’t quite fit into a checkbox somewhere else. Commonly, and this is really common with electronic records is the use of flowsheets. Flowsheets are like spreadsheets that talk about very specific info. But the narrative is where you “paint the picture” of what is actually happening during your shift, or with particular instances, that may not fit into the spreadsheet anywhere.

An example would be like, 0800, called Dr. Smith, discussed neuro change with patient, addressed need for stat CT, received new orders.

It’s quick and to the point, but there may not have been checkboxes on your flowsheet for those pieces of information.

Be sure to chart objectively (so what you saw) and to also make sure that you use quotations for what your patient says or experiences.

Now we’ll look at double documentation or “double doc’ing.” What double doc’ing is, is when you document the same thing in two places in the chart. This doesn’t seem like a big deal, but when you do it, it does two things. First, it’s time consuming and not efficient. If you’ve already charted something somewhere, there’s not a need to do it elsewhere. The other thing it does is that it potentially sets up for misinformation – like the charting doesn’t match. This is falsifying documentation and we want to not put ourselves at risk because of this.

Let’s look at an example. Let’s say you have a complete flowsheet for your head to toe assessment. It allows you to document everything you need to. You wouldn’t THEN go into a nurse’s note and RECHART your entire assessment. It’s inefficient AND it sets you up to forget something or put conflicting info.

At the end of your shift, you should always, always, always check your charting. Create a checklist that you KNOW what you have to do in your charting. Big things are like restraints, turns, pain assessments…make sure those things are in your chart. By doing this, you avoid discrepancies and ensure that all of your charting is complete and accurate. Even after many years, I still do this!

With so many different software systems in hospitals, we can’t tell you how to use each one of them. But one thing we can tell you are a few tips that might come in handy with most of them.

They all have shortcuts or “hotkeys” which make charting more efficient. Just make sure that you follow your hospital’s policy in terms of what you are required to chart at a minimum for them, and then know what you should chart for YOUR minimum.

Just make sure you pay attention in the computer training so that you know what to chart, and where and how you can do it quickly!
Finally, there’s this one thing that I want to stress. It’s really, really important. There’s this idea that charting is this huge, daunting task that has to be done and almost that it overshadows everything you do is a nurse. Almost that half of your time as a nurse is spent charting. That’s just not the reality of it. It is vitally important – it’s direct reflection of your care. But, you’ll get faster and more efficient with it.

The one thing that you absolutely have to remember is that no amount of charting is ever worth not doing care for your patients. You should never have the mindset or excuse that “I can’t do this thing for my patient” because I have to chart. There are only a handful of times I can think that looking at or doing anything with the chart would come before care of my patient, and that would be something like verifying a surgical or procedural consent. Or making sure that a resident was approved to do something. Other than that, patient care comes first.

There’s lots of cheats to make that more efficient. Use a strip of tape or a paper towel to write down notes, or I’ve even used something like a time tape to hold all of my patient’s info. And I could jot down little things to remember what they were so that I could chart them later, especially when my patient was tanking.

Also, always reach out for help. You’ve got other nurses and team members on your unit to have your back, so ask them to help you pass out meds if one patient gets super sick. Don’t forget to delegate anything you can so that you can focus on patient care and still get your charting done!

Nursing concepts for this lesson are both communication and health information technology.

So let’s recap:

Don’t forget when you’re charting that everything is being watched. So make sure you follow HIPAA and that you chart appropriately.

When using the nurse’s note, paint a picture that you can’t do anywhere else or in the flowsheets.

Don’t double doc. It’s inefficient and it can cause discrepancies.

Always review your charting at the end of shift to make sure you did everything you needed to.

Lastly, never sacrifice the care of your patient for your charting. You can always come back and chart later.

We hope you enjoyed these pro-tips to make your charting easier. Make sure you check out all the resources attached to this lesson. Now, go out and be your best selves today. And, as always, happy nursing!!