Enhancing your Charting

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No. 1:Document care completely, concisely and accurately. Write clear sentences that get right to the
point.
Use simple, precise language. Clearly identify the subject of each sentence Dont be afraid to use the word I. Wrong: Communication with pts home

initiated today to delineate progression of desease process and describe course of action. Right: I contacted Andrea Sovaks daughter by 4/29/12 phone at 1300 hrs.; I explained that Mrs.

Examples: Cont:
Wrong: Pt. Deceased at 0150. Next of kin

notified. Burns.

Right: Patient pronounced dead by Dr. Ted Dr. Ted Burns notified Mary Ritt, sister of

patient, via telephone of patients death.

Avoid using vague language (i.e. Appears or

apparently)

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#2 Maintain objectivity
Avoid subjective statements ( Pts level of

cooperation has deteriorated since yesterday). Instead use patients exact words to describe the facts that led you to this conclusion. patients condition is okay as long as you also record the objective assessment data that supports it. observe yourself or data from a reliable

Charting subjective conclusion about the

Document only data that you collect or

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#3:Ensure Timeliness
Chart as soon as possible Note exact times Chart chronologically Handle late entries correctly Dont chart in blocks of time such as 0700 to
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#4: Ensure legibility

Use ink and not pencils. Use only black or blue ink.(red and green are

usually used for night shifts.)

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#5: Use approved abbreviations.

Avoid these abbreviations!! Apothecaries symbols (fl. Oz, fl. Dram, minim,

scruple)

Use complete spelling for drug names.

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Correcting errors properly

When correcting a mistake, draw a single line

through the entry and write mistaken entry along with date and time.

Never erase a miste, cross it out or cover it

with correction fluid because this looks as if youre trying to hide something. sad face anywhere on a document is unprofessional and inappropriate.

Writing oops! or sorry or drawing a happy or

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5 donts
Dont add information at a later date without

indicating that you did so.

Dont date the entry so that it appears to

have been written at an earlier time.

Dont add inaccurate information Dont omit information Dont destroy records.

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Doctors orders
A second person mjust double-check the

transcription for accuracy. right patient.

Make sure the orders were written for the Clarify orders from the doctor if the order is

unclear.

ALWAYS clarify orders.

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Verbal orders
DNR and no code orders should not be taken

verbally.

Try to take verbal orders only during

emergency when the doctor cant immediately attend to the patient.

Usual procedure for verbal orders:
Record the order verbatim on the doctors order

sheet, or enter it in the computer. Note date and time.

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On the first line, write verbal order then write

doctors name and your name as the nurse

Verbal orders continued.

Sign your name. Draw lines through any space between the order

and your verification of the order. your verificatio of the order.

Draw lines through any space bet. the order and Make sure the doctor countersigns the order

within the time limits set by your facility. Without his countersignature, you may be held liable for practicing medicine without a license.
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Telephone orders
Ideally, you should accept only written orders

from a doctor. However, telephone orders are permissible when:

docotr isnt available to write an order.

The patient needs immediate treatment and the Youre providing care to the patient at home

(orders must be signed by the doctor according to state nursing practice regulations. Failure to do so could jeopardize reimbursements.) has become available and the telephone order 4/29/12 will enable you to expedite care.
New information (laboratory data, for example)

Examples
Telephone order Verbal order.
Telephone order. J. Marks to Mary Jones, RN; Lasix Verbal order. Dr. Dr. Bartholomew White to

40 mg I.V now and daily starting in am.--------Cathy Phillips, RN. Demerol 15 mg I.M. Now for Mary Jones, RN pain. ---------Cathy Phillips, RN

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Reference:
Lippincott Williams and Wilkins. (2006).

Charting made incredibly easy (3rd ed.). Philadelphia, PA: Author

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