"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

This may not always be something that you are able to do, but charting as soon as you have done something is going to help with the accuracy and further patient care plans. 

4. Be Objective

Do not chart what someone told you. Only chart what you have experienced. If you are charting what the patient has said, indicate it as "Patient states...". 

5. Educate Yourself with the Employers Abbreviation Policy or Standards

Different employers may have different standards in abbreviations.  Knowing what is allowed and not allowed can be helpful in writing accurate reports.

Some additional tips:

-Use blue or black ink

-Be concise and to the point

 -Do not state your opinion

-Do not erase or alter charts

-Do not chart ahead of time

-Do not write a novel

  

Careful attention to charting is never a waste of time. It helps you demonstrate the good care you’ve given. Remember that your patients are counting on you, so take pride in your charting.

In addition, we all make mistakes and hopefully they are minor and can be corrected. Please enjoy these charting mistakes from NurseLabs 

Assessment
All charting errors starts with assessment, of course.
1. “On the second day, the knee was better, and on the third day it disappeared!”
2. “Patient has chest pain if she lies on her left side for over a year.”
3. “She is numbed from her toes down.”
4. “Cough with flame” (I guess that nurse’s patient was a dragon!).
And did you know that rectal exams can now reveal the size of your thyroid?
5. “Rectal examination revealed a normal sized thyroid”. Or maybe, that nurse has really long index finger.
Another thing, assessment cues like these can be really confusing:
6. “Skin: somewhat pale but present.”
7. “The skin was moist and dry.”
8. “Occasional, constant, infrequent headaches.”
9. “Patient was alert and unresponsive.”
Medical History
10. “The patient has no previous history of suicides.”
11. “The patient has been depressed since she began seeing me in 1993.”
12. “She stated that she had been constipated for most of her life, until she got separated”, that patient’s marriage must be really awful, talk about getting a relief!
13. “Patient has two teenage children, but no other abnormalities”, DSM-V now indicates that having teenage children is an abnormality.
14. “The patient was to have a bowel resection. However, he took a job as a stockbroker instead.”
Weird Nursing Diagnoses 
15. “Acute pain related to witchcraft”.
16. “Bowel incontinence related to shyness”.
17. “Insomnia related to computer games”.
Interventions & Others
18. “Discharge status: Alive but without permission.” I didn’t knew that hospitals now issue permissions for you to be alive.
19. “The patient refused autopsy.” – LOL
20. “With 02 inhalation via foley bag catheter attached to urobag.”
21. “Advised patient to take a bath”
22. “IVF consumed and terminated then replaced with the same IVF”
23. “Regulated IVF to KVO to run for 2 hours”
24. “While in ER, she was examined, X-rated and sent home.”
25. “The lab test indicated abnormal lover function.”
And the winner is: 
26. “She has no rigors or shaking chills, but her husband states she was very hot in bed last night”.

Works Cited:

Quan, K. (n.d.). Best Practices for Charting. Retrieved July 17, 2017, from http://nursinglink.monster.com/benefits/articles/149-best-practices-for-charting  

Buppert, C. (2012, August 21). Nurses: What Is the Most Important Documentation Advice? Retrieved July 17, 2017, from http://www.medscape.com/viewarticle/769148 

Quan, K. (n.d.). Best Practices for Charting. Retrieved July 17, 2017, from http://nursinglink.monster.com/benefits/articles/149-best-practices-for-charting

Quan, K. (n.d.). Best Practices for Charting. Retrieved July 17, 2017, from http://nursinglink.monster.com/benefits/articles/149-best-practices-for-charting