Guidelines for Documentation in Nursing

Like many new nurses, you’re probably thinking about the ways you’ll apply your wealth of medical knowledge to care for patients in need. But once you complete your program, pass the NCLEX with flying colors, and ace your first job interview, there will certainly be some aspects of beginning your nursing career that you didn’t anticipate. One of those might be the processes of charting and documenting information in your new role.

Your patients’ well-being depends on accurate information passed from physicians to pharmacists. While it may seem intimidating to take on charting and documenting for the first time, you don’t need to be worried as long as you study up on the basics and maintain a can-do attitude.

Do’s and Don’ts of Charting and Documenting in Nursing

Do Memorize Workplace Policies

Every nursing job is a little different, and that’s the case with workplace policies, too. Once you understand the correct way to chart information, you’ll be able to move forward doing it correctly without running into issues later. Charts can in some cases be used in legal proceedings, in which case you’ll want to be sure you’ve not only done your job correctly, but you’re in line with workplace policies as well.

Don’t Be Too Busy for Accurate Charting

The challenges of nursing can seem to double when the workplace atmosphere gets busy. Whether it’s a day with tight staffing or an unexpected influx of patients, things can go from calm to chaotic at the drop of a hat. But those busy times are actually when it’s most crucial to take extra care with chart accuracy. Your brain may want to write quicker or leave out small (but significant) details while writing a chart before rushing off to the next task. Counteract that tendency by taking a few deep breaths and checking your work with extra care during those hectic moments.

Do Write Legibly and Learn Abbreviations

Have you ever wondered why doctors are famous for their impressionistic handwriting? The stereotype certainly shouldn’t include nurses. Nurses are expected to write as clearly as possible when charting anything on paper, which is why most of them are careful writers. It’s also important to know that any abbreviations you use are standard for the industry. Don’t assume others will understand your shorthand. It may be worth asking for a list of commonly-used charting abbreviations early in your first nursing job.

Don’t Include Your Opinion

It can be hard to keep opinions private, but any speculative information — not to mention anything that’s strictly subjective — should be kept off your patients’ charts. Opinions are especially susceptible to becoming skewed in a telephone-game interpretation by other caregivers. Including opinions may also appear unprofessional in the eyes of your colleagues.

Do Ask Questions

New nurses are expected to walk onto the job with a great foundation of knowledge and experience. But that doesn’t mean you should pretend to know the ins and outs of charting and documentation like a seasoned pro. It’s normal to ask questions, and can even help you make a good impression at your first nursing job. Being concerned about getting things right is a central trait of any good nurse, and it’s smart to look to those with more experience when you’re unclear on a detail of the charting process. Trust that you have the common sense to look up any information you can, and ask only the questions you can’t reliably find the answer to elsewhere. Later in your nursing career, you’ll be able to return the favor by answering charting questions for a new nurse!

Don’t Chart in Advance

Even if you know exactly the type of care that will be administered to the patient, don’t chart in advance. Charting should always be done soon after procedures, tests, or treatments takes place — not the other way around. One reason for this is that an interruption or change could occur, which would make it too easy to forget to go back and change what’s been written. On that note, any situation in which the chart will need to be erased or altered should be avoided. Think of the patient’s chart as the story of their care: Once anything takes place, the story is recorded.

Nurses are known for saying, “If you don’t chart it, it didn’t happen.” That’s because an accurate, well-documented chart of a patient’s care is the main way doctors, pharmacists, and every other caregiver along the way will know what has previously occurred for the patient. So if there’s no record, it’s as if a result or treatment didn’t happen as far as the narrative of care is concerned.