Nurse Charting Tips and Tricks to Nailing Patient Charting

Charting in nursing provides a documented medical record of services provided during a patient’s care, including procedures performed, medications administered, diagnostic test results and interactions between the patient and healthcare professionals. Nurses have a tremendous responsibility to accurately complete patient charting, which is vital in preventing medical errors, delivering high-quality patient care and protecting medical staff from liability and malpractice claims.

Search Nursing Jobs

5 tips for charting in nursing

Ensure your patient documentation is as accurate, useful and completed in a timely manner with these five helpful nurse charting tips.

1. Find balance

“Nurses are taught to live by the credo ‘If it wasn’t charted, it wasn’t done,’” says Catherine Burger, RN, BS, MSOL, NEA-BC. “That said, nurses must balance the requirement of charting care provided with actual face-to-face time with the patients. In the age of the electronic medical record (EMR), nurses who are able to integrate technology at the bedside will find an efficient flow to documentation and patient interaction.”

2. Use technology to the fullest

Burger emphasizes the importance of nurses learning to use the EMR to their advantage when completing their nursing chart. “Many EMRs are designed to list body systems in a specific order, with a ‘Within Normal Limits’ as the default. If the nurse’s assessment of the patient is normal, except for lung sounds, the nurse should note abnormal lung sounds and just ‘validate’ that the remaining exam is within normal limits.”

3. Avoid double-documenting

Burger also points out that some seasoned nurses have a difficult time giving up the “play-by-play narrative note.” She explains that “with the design and functionality of the EMR, most information is contained in flowsheets and data sets. Nurses should refrain from wasting time double-documenting in a narrative and the flowsheets. Nurses should use a narrative note only when needing to tell the story of a patient event or when there is a designated shift summary link for the care team.”

4. Document in real time

“Nurses should strive to document in real time as opposed to batching their documentation,” warns Burger. “Studies have shown that it takes longer to batch-chart than it takes to document the care at the point of service. Another important reason to document in real time is the ability of many EMRs to use predictability models in the programming that actually alert the nurse, or rapid response team, that the patient is declining or expected to decline.”

5. Avoid pre-charting

The busier you are, the harder it is to keep your nursing charts updated, which is when errors and omissions are more likely to occur, reports the Denver College of Nursing. This is also when it’s most crucial to carefully document your actions. However, never chart in advance. Wait until tasks are completed to avoid potentially serious repercussions.

Apply Now

Latest Blogs

Take the first step to starting your new career.

Authorized to work in the US? *
Job Type Interest *
Have you been on an Interim engagement with AMN before? *
Are you currently employed or on an active Interim engagement? *

How much notice would you have to give? *

What date are you available to start an Interim engagement? *

* Indicates Required Fields

 

I agree to receive emails, automated text messages and phone calls (including calls that contain prerecorded content) from and on behalf of AMN Healthcare, and affiliates. {{show_more}} I understand these messages will be to the email or phone number provided, and will be about employment opportunities, positions in which I’ve been placed, and my employment with AMN companies. See privacy policy or cookie policy for more details.

Complete Your Application!
AMN Healthcare NurseFinders logo
Continue to NurseFinders to complete your application and profile.