Updated: Nov 15, 2019
This is definitely on my top 5 list of things I have so much to say about!! After a long day of seeing patients, barely taking a break to eat or pee, remembering to order medications/supplies, possibly getting new medication/treatment orders from the MD... charting is the thing most of us dread doing. BUT it is one of the most important things we do for so many reasons.
Nothing frustrates me more than preparing to see a patient, especially for the first time, and not finding any current documentation in their chart. This is unacceptable to me. It's bad enough to see minimal information documented but to not even have the last visit started makes me scream. Internally. Oh!! And don't get me started on things that are left out of the documentation.
If you know me, you know my charting is always way too long and wordy. I understand this and I do not expect others to follow suit. But I see documentation as a road map of the decline of the patient. In my first days of nursing school, we were told to write our documentation with the idea that many years down the road, for whatever reason, someone may be looking at your charting. Your job, is to make sure there is no need for questions, because you made yourself very clear AND created a detailed picture of what that patient was experiencing during your visit. Write everything you can so no one needs to question you.
So this is what I think about when I chart; I think about WHO will read it. I start with the MD and what information I think they would want to know. I think about the Case Manager or other nurses that might see this patient. I think about the social worker and the chaplains and make sure I incorporate any dynamics or spiritual questions/concerns. I also think about the caregivers, HHA's and volunteers.
I always include intake/output, emotional state, pain level, skin changes, family dynamics, near death awareness/concerns and how quickly their decline might be. If the patient is in pain and has been taking additional pain meds, or increased PRN's, I include date/time/dose, so that the MD/CM can keep track. I also include areas of sensitivity, for instance; "left sided weakness", or "don't touch right shoulder". Provide the information that will best describe what the patient is currently experiencing, but also what will help those seeing the patient after you. Your words can determine the care that patient receives after you. You can help make sure they are tended to appropriately, kindly and considerately.
Imagine you saw a patient and there was a significant decline, or medication change, or information you gave the family that was valuable and important but you didn't document after your visit. And then something happens, shortly after you left, so they called the after-hours/triage nurse to discuss it. The person answering the phone goes to that patient's chart and does not see anything, has nothing to go on. This is not fair to the triage nurse, the family member or the patient.
Charting is important!! Do it as soon after your visit as you can and do it with thought and consideration!!! And if you don't have the time right after your visit, at the very least, add the significant stuff in the narrative so there is something there. I get it, the days are long and it's really hard to chart after your visit, but this isn't about you. This is about the care our patient's receive and that is our responsibility. :)