You covered a lot of ground in nursing school. While you may feel more than ready to place an IV or take vitals, you might be a little less confident when it comes to charting. It might seem strange that the paperwork is what makes your palms sweat, but it makes sense. Patient documentation is permanent record, and, well, you probably became a nurse for the hands-on interaction.
That’s OK! Here’s a refresher on what and how to chart as a nurse, as well as tips for avoiding some of the most common documentation mistakes.
The Importance of Documentation in Nursing
Charting isn’t an afterthought or mindless paper-pushing; it’s a crucial part of your role as a nurse, says Michael Zychowicz, DNSc, MSN, BSN, a clinical professor of nursing at Duke University’s School of Nursing. Effective documentation can:
- Help a large, interprofessional healthcare team communicate with each other.
- Ensure that the quality of patient care doesn’t suffer from one shift to the next, or while being transferred across care teams.
- Create a record of billable services for insurance companies or other payers.
- Protect you in the event of a lawsuit.
- Demonstrate your contributions as a nurse.
What Types of Things Should You Document in a Patient’s Chart?
The information you put in a patient’s medical record should more or less track the nursing process. Your charting generally should include:
- Authorship Details: For example, the date/time the note was written, as well as your full name, credentials, and signature.
- Your Assessment of the Patient: This includes your interpretation of the findings and any diagnosis.
- Objective Data: What your assessment told you.
- Subjective Data: What the patient told you.
- Plan of Care: This includes modifications to an existing care plan, evaluation notes on how well the care plan is going, or self-care instructions for the patient.
- Interventions You Implemented: For example, any procedures or medications administered.
- Consultations or Referrals: This includes details about the provider’s name and affiliation.
If you aren’t sure you’ve included everything you need to, ask yourself: “If another nurse needed to step in and care for this patient, would the chart give them everything they needed to do it seamlessly?”
What Are the Different Types of Nurse Charting?
Nurses have different ways of charting similar information, and there’s no one best way, says Krysia Hudson, DNP, RN, BC, an assistant professor at the Johns Hopkins School of Nursing. As long as you get down all the important information, Hudson says, it doesn’t really matter how you go about it. That said, there are a few different approaches you could take, and each has their own advantages and drawbacks.
1) Narrative Notes
Narrative nurses notes are like a running log of everything that happened with the patient during a particular shift. The benefits of narrative notes are that they’re straightforward, easy to do, and simple to follow. At the start of a shift, nurses can read through the log and get a good sense of what happened before they arrived.
But narrative notes can also be pretty repetitive and disorganized. Nurses during different shifts might be focusing on different problems, and you have to read through the entire chart to get a real feel for how the patient is doing overall. Another drawback, according to Hudson, is that even seemingly objective notes could, in reality, be subjective. You could use three words to say a foot looks pink, but other healthcare providers might interpret that hue differently.
Example of Narrative Notes
|11/15/2013||0815||Assessment performed, resident with C/O SOB, states, “I just can’t seem to catch my breath, and I am coughing up green phlegm.” On auscultation, breath sounds decreased in bases bilaterally, coarse rhonchi bilaterally in upper lobes, accessory muscle use noted bilaterally, breathing is shallow and lips are cyanotic. Vital signs assessed; temp: 100.5, BP: 110/76, HR: 108, RR: 32, SpO2: 95% on room air. ‐‐‐‐‐‐ J.Smith, RN|
|0820||Assessment findings reported to Dr. Halifax ‐‐‐‐ J. Smith, RN|
|0825||Resident assessed by Dr. Halifax ‐‐‐‐‐‐ J. Smith, RN|
Example from the Texas Department of State Health Services
2) Charting by Exception
Instead of comprehensive note-taking, charting by exception (CBE) documents only things that are outside the norm. The beauty of CBE is that it takes significantly less time to do, giving nurses more time to focus on other tasks.
But while Hudson says she prefers CBE, it does have its downsides. In order to chart by exception, you have to first know what’s considered “normal” for any given patient. Every organization has its own defined limits, and those standards might not actually reflect what’s “normal” for some patients. For example, someone who has had a liver transplant might never have bilirubin levels within a normal range. CBE can also leave out really valuable information that makes it hard to know whether a patient’s condition is changing or if certain procedures were truly conducted.
CBE can look very different from one healthcare environment to the next,
depending on the documentation tools they use. Many clinical settings that use CBE generally rely on checklists and flow sheets to document patient information, allowing nurses simply to check some boxes or quickly sign their initials before moving onto the next patient.
CBE: Checklists and Flow Sheets
These pre-made templates (usually one to two pages when they’re printed out) list all the data, services, and measures relevant to a particular type of visit, assessment, or condition. They consist mainly of boxes to check and short, blank spaces to fill out, making them typically quicker and easier to fill out than, say, writing a long narrative.
The standard template also makes it easy to compare metrics across visits or spot anything out of the norm for the patient. For example, if you have a standard admission template that always has vital signs along the top of the page, you can easily see if the patient has gained weight or lowered their blood pressure compared to previous visits.
But the information conveyed by flow sheets or checklists is far from exhaustive. With little room for narrative, these templates only provide a narrow snapshot of what’s happening with a patient. As a result, they’re often used to complement (rather than replace) other forms of nursing notes or charting.
3) SOAP(IER) Notes
SOAP(IER) stands for “subjective,” “objective,” “assessment,” and “plan,” with some nurses choosing also to add “intervention,” “evaluation,” and “revision.” Nurses generally use this acronym to guide them when they’re charting about a particular problem or medical condition. It’s broken down like this:
- Subjective: This section covers history (e.g., medical history or symptom progression), as well as any relevant information, questions, or concerns told to you by the patient or their friends or relatives.
- Objective: This is where you add the hard data (e.g., vital signs, labs, exams, etc.) observed during the visit.
- Assessment: Once you note the observations, then you can move on to your assessment. What is the primary medical concern? What else might be going on? Whatever you put here should be supported by the information given in the first two sections.
- Plan: Now that you have your diagnosis, what should happen next? Use this space to discuss the outline or updates to the patient’s care plan, including any prescriptions, self-care instructions, follow-ups, or referrals.
- Interventions: Here’s where you put anything you did for the patient to address the problem identified. Did you give them medications? Put up the bed rail? Place the call button within reach? Don’t forget any instructions or education you verbally conveyed to the patient.
- Evaluation: This section is where you note how well the intervention(s) worked, usually in the form of objective or subjective data.
- Revision: If your evaluation signals that you should tweak your intervention, you’d then note here what changes (if any) are being made to the care plan.
While SOAP(IER) notes have been widely used in healthcare settings, they’re becoming less and less common, Hudson says. This is due, at least in part, to how time-consuming they are. Using this process for each individual problem can mean inputting a lot of the same information, especially if problems overlap.
Example of SOAP(IER) Charting
Example adapted from Fundamental Nursing Skills and Concepts, page 114
4) PIE Charting
Similar to SOAP(IER), PIE is a simple acronym you can use to document specific problems (P), as well as their related interventions (I) and evaluations (E). Nurses write down their assessment on a separate form or flow sheet in the patient’s chart and assign each individual problem a number. Every time they refer to that particular issue in the patient’s chart, they use that assigned number.
The whole process is problem-oriented like SOAP(IER) and covers much of the same ground, but it’s a little simpler to use.
Simpler, however, isn’t always better. Unlike more comprehensive documentation processes, PIE charting doesn’t specify a fundamental care plan. That means different nurses might try to solve the problem in different ways, potentially resulting in inconsistent care.
Example of PIE Charting
Example from RN.org
5) Focus (DAR) Charting
Focus charting uses the DAR process (i.e., “data,” “action,” “response”) to guide and organize nursing notes. Similar to problem-centered charting, DAR charting organizes notes by focus (thus the name) that can span health changes, patient concerns, or specific events, in addition to traditional medical problems. The focus is identified during the assessment, and then nurses note the specific actions they took, as well as how the patient responded to those actions.
The big advantage to focus charting is that it’s easy to do because the steps follow the nursing process pretty closely. But it can also be a little confusing, especially for new nurses. The DAR statement is typically recorded in addition to other forms of documentation like flow sheets, which can make notes feel a little disorganized.
Example of Focus (DAR) Charting
Example from RN.org
Nursing Documentation Dos & Don'ts
As important as documentation is, mistakes can happen. Here’s how you can avoid some of the most common charting errors in nursing.
Nursing Documentation "Dos"
- DO document in a timely manner. Wait too long and your note might not be as accurate as it could be, or worse, other providers seeing the patient could be left without the information they need to do their jobs. If you have a delay in adding your notes, be sure to note that it’s a late entry so there’s no confusion over what happened and when.
- DO double-check templates to make sure they’re accurate. Electronic health record (EHR) templates and macros can be huge time-savers by automatically filling in notes for routine exams, but they can also introduce errors into the chart if you’re not careful. Make sure every checked box and note is accurate for the individual patient.
- DO verify that you have the correct chart. The name might be right, but is the birthdate? Even with EHRs, chart mix-ups can happen, and that can lead to medical errors. Before jotting down your notes, be sure that the file you’re looking at truly belongs to your patient by following the Joint Commission’s standard of using at least two personal identifiers.
- DO spellcheck. A typo or three might seem like no big deal in the grand scheme of things, but even small mistakes can come back to bite you, Zychowicz says. In the event of a lawsuit, for example, a lawyer might try to argue that if you’re careless with your charting, you might’ve been careless in your other nursing duties, too. Be as professional with your documentation as you are with your patients.
- DO ask other nurses for tips and tricks. Nurses are being asked to take on more and more paperwork without more time to do it, and that can be overwhelming. Avoid burnout by asking your fellow nurses for their favorite shortcuts or techniques to make charting more efficient.
Nursing Documentation "Don’ts"
- DON’T make assumptions. If you didn’t see a patient fall on the floor, don’t put it in the patient’s record, Hudson says. You didn’t walk in and see that “the patient had fallen on the floor.” You walked in and “saw the patient lying on the floor.” Stick to the facts.
- DON’T use unclear abbreviations. Abbreviations can save time, but they can also cause confusion. Check your clinic’s policies and procedures for guidance on what abbreviations you can use. If you aren’t sure, spell it out.
- DON’T rely too much on transcriptions. Not all voice-to-text software programs or transcription services are 100 percent accurate. Sometimes words can be switched out or removed, effectively changing the meaning of the note. Before posting the text to the patient’s chart, read through it to make sure it says what you want it to say.
- DON’T leave out important information. When you’re rushed for time, it can be easy to leave out things that seem routine. But as the adage goes, “If you didn’t write it down, it didn’t happen.” Any contact with the patient (e.g., interventions, exams, instructions, referrals, etc.) should go into the chart. Leaving out relevant information could result in medical errors or lawsuits down the line.
- DON’T over-chart. You want to be thorough, and that’s great! But don’t feel like you have to write a novel in every chart or even use complete sentences, Zychowicz says. It’s just too time-consuming, and chances are you don’t really have the time. Chart what you need to, and then move along.