Accurate patient charting is an important part of a nurse’s job. Through nursing charts, nurses communicate important information to the entire healthcare team. A patient chart is also a legal document that includes details about medications administered, treatment provided and procedures performed. If you are a nurse, you should take the time to accurately fill the patient chart. Here are some tips for patient charting:
1. Over-chart than under-chart:
The golden rule in nursing is: if it’s not in the chart, it didn’t happen. This may seem like common sense, but you would be surprised how often you forget to document key details. Remember, your chart is a legal document that can be used in court of law if necessary. Charting slip-ups happen when you leave details such as:
- Current (or recent) medications
- Pre-existing medical conditions
- All aspects of a patient’s treatment, with timestamps
- Any known drug allergies
- Medications that have been administered
- Adverse reactions to a drug, even minor ones
- Discontinuation of a medication or treatment
2. Chart for others-not just yourself:
As a nurse, you play a vital role in ensuring that patients receive the best possible care. Part of that care involves providing detailed and accurate documentation so that other nurses can pick up where you left off. When writing your notes, be sure to include all relevant information, such as the parent’s current condition, medications, and any changes in their condition since you last saw them.
Ask yourself the below questions to figure out how your charting should look:
- Are the notes too vague?
- Do the notes seem subjective?
- Is the handwriting illegible?
- Are the abbreviations unclear?
Note: Always use standard medical terminology. By using standardised terminology, you can ensure that the correct information is being conveyed to other team members. Non-standardised terminology can be misconstrued and can lead to medication errors.
3. Don’t include your opinion:
It is important for you to remember that your medical records are not the place for your opinions. Instead, you should always chart objectively, recording only the facts of the patient’s condition.
4. Chart in real-time (within reason):
In the chaotic world of healthcare, it can be difficult to find time to document a detailed patient account. It is a good idea to make notes in a patient chart otherwise you may forget some key details.
5. Use eMAR nursing chart:
Many nursing homes in the UK are using eMAR nursing chart or top EMR systems to standardise patient’s medical history, medication documentation and promote concise charting. Using the eMAR nursing chart, you can follow a streamlined and systematic way of medication documentation and administration. If your nursing home has switched to eMAR nursing chart, here are some features you should know about:
- Audits: With an eMAR nursing chart, you can easily prepare monthly, quarterly and annual reports. This helps to ensure that the nursing home is meeting all the government guidelines.
- Alerts: The software sends you notifications when the dosage is due. This ensures that no dosage is missed and that patients receive their medications on time.
- Pharmacy integration: eMAR charts can be integrated with the pharmacy, which makes restocking medication inventory very easy.
- Notes: eMAR nursing chart makes it easy for you to prepare notes and record them. This helps to ensure that all important information is documented and easily accessible.
For more details about the eMAR nursing chart contact us.