How to Get Your Charting Done On Time

As a nursing student or nurse, you've heard the phrase "if you didn't document it, you didn't do it." This phrase is commonly used, and for good reason, as charting provides a documented medical record of the services provided to patients. 

However, with increasing patient acuity and understaffed units, nurses may be unable to chart on time. Here are a few tips on how to get your charting done and go home on time.

Consistent Charting Style

Remember when you were in nursing school and were given an assessment sheet to document for each patient? Why stop there? 

To streamline your documentation, create your own template that includes everything needed to be documented on your patient to:

• Avoid forgetting important assessment notes

• Know what you missed, as the document can serve as a checklist

• Give you a bird's eye view of what you have done for each patient, and refer to it when documenting in the electronic medical record

Optimize Technology Use

Most hospitals use computerized charting systems for documentation instead of pen and paper. Typing is faster than writing and eliminates the possibility of trying to understand illegible handwriting. 

Here are some ways to optimize the use of technology when you chart:

• Know keyboard shortcuts

• Instead of spelling out every single medical term, memorize the abbreviations that are accepted in your setting

• Computer charting systems usually have standardized patient flow sheets that you can choose from according to your patient diagnosis. Get familiar with these, as they allow you to chart what is needed for your patient situation and prevent you from over charting

Real-time Documentation of Abnormals

If you are behind on charting, don't feel like you have to chart your entire patient assessment the moment it’s completed. Get into the habit of charting abnormal patient findings first, and when you have time during your shift, go back and document the rest. 

Prioritizing what you document allows other providers to know what is happening to the patient in real-time instead of waiting for the information to be entered later, which can delay patient care.

What Should You Chart?

If you want to make sure that you have documented concisely, just remember the nursing process, and use this cheat sheet to help you "cross your t's” and “dot your i's":

• Do you have a date and time next to every note written?

• Did you document the objective data gathered from your assessment and the subjective data told to you by your patient?

• Did you document any abnormal findings?

• Did you update the plan of care for your patients?

• If you performed any procedures, did you document them?

• Did you document any patient teaching provided?

• Any new referrals or consultations that the incoming shift should know about?

Don't Use Subjective Language

Never use words that may or can easily be misinterpreted by others. It’s important to state enough details and facts to give another person an idea of what is happening without bias. Remember that everything you document can be used in legal proceedings, so just stick to the facts. 

Stop Trying to Achieve Perfection

The notes you write do not have to be perfect. However, the note should be brief, focused, and clear enough so that whoever is reading it can have a good understanding of what you’re trying to relay. 

Nurses are used to staying later to finish charting, but it should not be that way. The next time you go to work, try these tips and see how much time you save every day, which allows you to spend more time with your patients and go home on time.