Nurse Charting - How to Chart Accurately


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.

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