Nurse Charting - How to Chart Accurately
May 21, 2019 Updated: December 29, 2021 5 min read 1 Comment
Cathy explains that the first rule of charting is to NOT automatically follow what the charting says before you. She has learned now that charts are not always accurate, or they just copy the prior error stated before them. Cathy explains that at times she’s had to audit charting and has learned that charting mistakes are common. The most important advice here is chart only what you observe, regardless of what the charting says before you. Stay confident in your assertions.
As a practical matter, you sometimes have to cut corners. However, do not skip pressure injury charting because audits on these deficiencies are regulated and reported to supervisors. Another area to not cut corners on is pain assessment since pain medications are involved. Finally, Cathy explains how to remove adhesives or tape from patients, particularly elderly ones.
Hey, it's Cathy. And I know it's been a while since I have put out a video with some tips for you guys, just some tips in general as you're getting started on your nursing career. So I thought up a couple today that I wanted to share with you.
The first is not to automatically follow the charting that came before you. The charting before you can be completely wrong sometimes. So I know as a new grad when I would go do my patient assessment and I would not hear crackles, like the nurses before me would chart crackles or something else and I wouldn't hear it, and I would double-check, and I sometimes will second-guess myself like, "Well, I'm a new nurse. Maybe I'm just not hearing right. I'm sure they're probably right. Maybe I should chart crackles too." But I'd really warn you against doing that. So in the end, I would not do it, but I'd always second-guess myself, but I've been working long enough now to see that people chart some crazy things. There are things that are just not true or just copy the charting that happened before them.
So let me give you an example. So as a wound nurse, I do audits every Monday, Wednesday, and Friday on pressure ulcer charting. So when I'm looking there, I had a patient who had I think a stage two pressure injury on their coccyx, right? So on their backside. And a nurse, a couple of days ago, started charting that she put an ACE bandage on the pressure injury, which is not going to work out at all, like an ACE wrap on a pressure injury. And then a couple of other nurses copied that same charting after her. So three different shifts of nurses put that they were putting an ACE wrap on somebody's pressure injury, which makes no sense at all.
So I'm warning you that don't just copy the stuff ahead of you, do your own independent assessment, and don't second-guess yourself. It's good to see what was been charted, but always put your assessment, your charting as you see and as you hear it in the chart, okay? Because sometimes there's mistakes and you don't want to just be following up with those same mistakes. So that's one really important piece of advice because I think every new grad nurse I know has always felt like, "Ooh, they put this before me. I should probably do that." But that's really not the case.
And then speaking of charting, I wanted to give you some advice on where you should or shouldn't cut corners. So as a nurse in a perfect world, we would have time to do super thorough charting and to get everything perfect with our charts, but what you'll find or what maybe you've already seen is that a lot of times you're fighting fires and just trying to keep your head above water when you're on the floor, and there's not a lot extra time. If you have a patient who have a rapid response, somebody is going down for surgery, somebody's potassium level is super low, so you got to hang four bags of potassium, it just gets crazy.
So you want to do the really important charting and as much charting as you can. But I'm here to tell you that you don't want to cut corners in a couple of key areas. So one is pressure ulcers or pressure injuries. And I say that because I actually do the audits and when nurses miss their pressure injury charting, I actually have to notify their supervisors and charge nurses and let them know. This is because when the state, or J CO comes in to do their inspections and assessments, they look at this charting. If patients have gotten a pressure injury while they're in the hospital, that's hospital-acquired, that's a really big deal, right? So we don't get paid for their care in trying to resolve this pressure injury if they got it while they're in the hospital. And if they came in with it, it's really important that we take pictures of it and document it really, really clearly. So if a patient has wounds, particularly pressure injuries, you definitely want to chart on those, because if you don't, someone will come find you, probably your manager or supervisor and let you know, and then you have to fix that.
The other area that you never want to cut corners on is your pain assessment. So you need to make sure you're doing a pain assessment on your patients every day. And if they are having pain and you're giving them pain medication, you need to do an assessment prior to the medication administration, and then one following up. So if it's like an IV pain medication that you've given them, then the follow-up is going to happen pretty quickly after that, like 10, 15 minutes, probably 30 minutes on the long side. You want to follow up and see how they're feeling and what their pain level is. If it's oral pain meds, then that may take more like an hour before it would take full effect, and that's when you want to do your reassessment. But you definitely want to have those pain assessments documented before and after pain medication. And even if you're not giving any pain medication to a patient, you want to at least do one pain assessment per shift.
And then the last thing is around wounds, actually. So a wound nurse, I'm always eager to give tips on that. But I wanted to talk about how you should go about removing tape or adhesive from a patient's skin. So as patients get older, their skin is very, very vulnerable to being ripped. And so I've seen it more than once where a nurse or somebody will take tape off and the skin will come right with it, that top layer of skin. And now they have this gnarly skin tear, which is very, very painful. So when you are removing a patient's tape or adhesive, I'd really recommend trying to find an adhesive wipe remover, which should be in your supply room. Some people use alcohol swabs, which work pretty well. They're actually definitely better than nothing. But if you can find an adhesive remover wipe, then what you want to do is use a push-pull technique. So you kind of lift the corner and you want to push on the skin with the adhesive remover wipe and kind of wipe it back and forth as you pull the tape back. So you're pushing on skin while you're pulling the tape, not just pulling, because then the skin is going to rip, in all likelihood, if they're older. So using a push-pull and adhesive remover, and that takes away a lot of the pain and prevents injury to the patient's skin.
So those are my tips for the day. I hope they've been helpful, and good luck with studying. Take care!
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