Someone could probably give an hour-long speech about how to be a great charter, and how to chart defensively. Charting has become a major part of our work day. We have to learn to do it quickly and accurately in order to survive!
1. Chart in the room. This isn’t always possible, and it’s not always easy, but if you have a computer in your patients room, stop and chart! You will (probably) not remember everything you did at that moment later in the day. You will (probably) not remember what time you actually did it. So when possible, do not leave your patients room until you chart what you were doing. You can go back and edit or add later, but chart what you basically did.
2. Think about what you’re saying. How we say things in our charting matters. We cannot say I recommended THIS, but the physician did THIS, and now the patient is worse (no matter how much we may want to). Instead, we can say Recommended THIS. Physician verbalizes understanding. TO [something else].
3. Don’t forget to chart about comfort. Your patient’s comfort matters. Even if you did something little, like turned on the TV for your patient, chart that you did it to help promote patient’s comfort. Or to help distract patient from pain.
4. Document that your patient understood. When we educate, we need to document that our patient verbalized understanding. You can even chart a question you asked, along with your patient’s (right) answer, to ensure your patient understood the information given.
5. Note a physician’s presence. Even if their physician isn’t in their room, chart when they’re on the unit! And when the physician is in the room, document what they’re doing…assessing their patient and discussing the plan of care.