"If you didn't document or chart it, it didn't happen."
A popular saying in any medical setting is "If you didn't document or chart it, it didn't happen." Documentation and charting is an essential part of the job for all healthcare professionals including nurses and nursing students. It is important to learn how to chart correctly early on in your nursing career so that you develop good habits right off the bat. The medical chart is a running record of everything that has been done in regards to the patient care. All information in this chart will help anyone involved in the patients care. There are several things to keep in mind when charting. 1. Legibility If you are documenting by hand, you need to make extra sure that everyone can read it. 2. Accuracy A very important point in charting is accuracy. You may have given the patient the correct dose of a medication, but if you charted it inaccurately that is what is going to be assumed that you did. 3. Timing Th...