Efficient charting is one of the main characteristics of an excellent nurse. Charting about what goes on during your shift can be helpful to the oncoming nurse or to the doctor that wants to check on the patient. The art of charting is a skill that can be perfected with experience, resulting in the ability to perform the task well and in a timely manner. Below are a few tips for a quick and successful charting experience.
1. Know Your Charting System
Most facilities have moved into this century and implemented some type of electronic medical record. Make sure you familiarize yourself with the system before your first solo shift. There are many different systems to choose from, such as PointClickCare, Matrix, Medisoft, and Optimus. Your facility should provide ample training time to employees, as well as technical support when needed.
2. Chart Throughout Your Shift
Take a few minutes to occasionally chart during your shift. You should be familiar with your facility’s charting procedure and have a list of patients that require charting each shift. Try to get into the habit of charting after you provide patient care. This can ensure accuracy, as well as eliminate staying over to complete charting at the end of the shift.
3. An Eye Details
Include all important information and details when charting your notes. Some patients may require specific details for ongoing monitoring to be included in their notes for each shift. Be sure to check for any additional information that you need to include when charting your notes.
4. Be Consistent and Clear
Some systems require charting the same information in multiple locations. Pay close attention when charting in multiple locations and make sure you enter the correct information in all areas. Check to be sure that all of the details match and that you’ve worded your charting in a clear, easy to read and understand manner.
5. Increase Your Typing Skills
Practice makes perfect, right? The more you practice typing, the faster you’ll get. So…in theory, the more you chart, the faster you’ll type! Charting will become easier, almost second nature, when you’re more familiar with the charting system. Once you get accustomed to navigating the system, charting will be a breeze!
6. DO NOT COPY AND PASTE
I know it’s tempting. You’ve been on your feet the entire shift and you’re ready to clock out and go home…..but you still have to chart. Whatever you do, don’t give in to the temptation of copy and paste. Even if you change a few words in your notes here and there, management still recognizes a copied note. A patient’s details may change from one day to the next, so to ensure accuracy, always create your own notes for each shift.
In conclusion, charting is a tedious task that most nurses don’t look forward to. For the greater good, we do tolerate this little bit of unpleasantness. It’s all done for the purpose of communication. Communication is a key factor in providing excellent care to our patients. So, we have to take the good with the bad and do what we do best!
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