Charting is as inevitable as death, taxes, and med pass. If you don’t chart it, it didn’t happen.
The question is, though, how to chart efficiently so that you can get the rest of your job done. It seems like an overwhelming task to chart every little think, so how are you supposed to do it all?
Nurses are often expected to do it all, but there are actually some tricks to getting through charting hell. Here are three tips that can help you chart efficiently, get your job done, and hopefully, get out the door on time.
Chart as you go
The main tip is to chart as you go because it is so easy to forget things. If you wait until the end of the shift, you will be wracking your brains to try to remember what happened at the start.
This is no way to chart efficiently, because it will take you much longer to remember and chart it. Instead, find a way to make notes in the system as you perform your assessments, med passes, or handle patient problems.
It may seem overwhelming at first and more bother than it is worth, but if you work it into your routine, you will find that it is far easier than the alternative. Try it for a week, and you will become a convert.
Follow a set pattern
Most nurses follow a set pattern when they chart, and this helps keep them organized. Many nurses have learned the SBAR technique and the SOAP notes paradigm that is taught in nursing school.
If you haven’t heard of them, a quick Google search will bring you up to speed on what these organizational acronyms can do for your charting. Of course, you can simply go head to toe for assessments or chronologically for incidents.
The point is that you need to have some sort of organization to your charting for it to be efficient. If you are flailing at the keyboard, only writing down what you remember then you are going to spend an awful lot of time writing your notes.
Use the computer system
Most computer systems have notes built into them already, and it would be best to use them. Use the check boxes and pull down menus to quickly chart on routine items like assessment and med pass.
This is probably the most efficient way to chart if your facility has this capability. However, you should not overlook the section that allows for comments.
Just because the checkboxes are all filled in doesn’t mean the whole story has been told. Take the time to type a few lines about your patient’s specific issues, and it will help you to make the most complete note possible.