How Do I Chart That?
"How do I chart that?" Has this question come up after caring for a challenging patient or after a crisis has occurred? Documentation in a patient's record is difficult for many nurses because information has to be both condense and clear. Recently, I attended a seminar about legal consequences of poor documentation. To my surprise, poor handwriting was not always the culprit.
One of most important lessons learned about patient documentation is that you cannot write how you speak. I never really learned this in nursing school. But I have observed doctors and nurse practitioners write in a specific structure when documenting patient care.
Example: you learn a patient is presenting signs and symptoms of low blood sugar. He tells you he feels his heart racing. You check his blood sugar, then instruct a nurse assistant to ask for assistance from the charge nurse. The charge nurse notifies the doctor as you remain with the patient. The doctor gives a verbal order to give an intramuscular injection of 1 unit (1 mg) of GlucaGen. The doctor arrives to assess the patient. The patient presents signs and symptoms of recovering from the hypoglycemic episode. You re-check the blood sugar and learn that his glucose level is within expected range.
So, how do you chart that?
First, write was observed - but don't write as you speak. Don't write, for example, something like this: "I found Mr. XYZ in bed in his room looking tired and sweating a lot. When I asked him what was wrong with him, he told me his heart was 'beating fast' and started talking weird. He was breathing really fast and starting peeing on himself. I checked his fs [finger-stick] and found out he was 45. I told the charge nurse what was going on and she called the doctor. The doctor said to give him a shot of GlucaGen and he was on his way over. The doctor was there in no time. I asked him if he knew what happened and he told me his name and was asking, "What happened?" I re-checked his fs like he asked. Mr. XYZ started to come through and he was no longer confused. I told him to stay in bed while the nurse assistant cleaned him up."
OK. Now, this tells the reader what happened, but it is not professionally stated. A more expected style to document: "During patient rounds, writer observed patient reclining in bed, sweating profusely. Writer assessed. Patient lethargic, incontinent of urine x1 episode. Used inappropriate responses to commands. He stated heart was ‘beating fast.' Blood glucose was 45. Charge nurse and attending notified. Verbal order to give 1 milligram (1 unit) of GlucaGen IM. Given right deltoid as ordered. Attending at bedside within 10 minutes of notification. Writer re-assessed patient. Patient asked, "What happened?" Verbal order to re-check glucose. Blood glucose 115. Writer instructed patient to remain in bed. Nurse assistant changed clothes and linens. Will have meal trays delivered to room. Will continue to monitor."
You immediately notice that the writer speaks of him/herself in third person. Sentences are short and actions are written succinctly; often articles such as "the" "on" or "in" are left out for improved clarity.
For me, at first it felt unusual to write in this manner because it was if I wasn't writing in complete sentences. But I learned charting in a patient's record is not the same as writing a research paper. The purpose of documentation for patient charts is to state what happened and what was done in a succinct and clear style. Personal opinions and abbreviations can lead to legal dilemmas.
Here are a few important "DO NOT" rules I learned from a nurse attorney:
- DO NOT mention staffing or delegation matters in a patient's chart.
- DO NOT mention medication errors in a patient's chart. In the patient chart, document only what was given.
- DO NOT chart, "Patient non-compliant." Chart, "Patient did not adhere to or did not take medication."
- DO NOT quote profanity used. Instead chart, "Patient used profanity toward writer/staff."
- DO NOT chart the patient was "hostile." Instead, chart the actions that describe hostile behaviors.
- DO NOT chart patient "incompetent." This is a legal court-ordered decision. Instead chart, "patient was incapacitated."
- DO NOT chart "error entry." Instead chart, "Mistaken entry in chart" or "Written in wrong chart."
- DO NOT chart "drug-seeker." Instead, report the facts of what was observed and what actions were taken.
- DO NOT use abbreviations. Write out as much as possible. Definitely avoid slang abbreviations (i.e., OMG).