I often tell people that I was practicing nursing back in the days when dinosaurs roamed the Earth! We didn’t have computers then and we didn’t have charting by exception. We only had what we would write down in the paper chart medical record.
While progress in technology has since made documentation so much easier, these advances may not always be in the nurse’s best interest. When all you need to do is check the boxes to record how the patient is doing, it’s hard to make sure that A + B = C.
Just this week I was looking at a case where the patient had profound dehydration with elevated sodium and the nurse is documenting “moist, mucous membranes and normal skin turgor.”
How can this be?
Before you go checking off any of those boxes, think through the patient’s situation and diagnoses to make sure that what you are documenting adds up. If it doesn’t, then write a narrative note to explain why.
Although charting by exception can save time, blindly checking boxes is neither your or the patient’s best interest. Like any form of documentation, your judgment and common sense is what’s important. Just ask yourself, “Does my documentation tell the full story of the patient’s condition, professional assessment and care?”
Just checking a box, say, about wound drainage being bloody leaves out specific information such as the color, consistency and quantity of the drainage. When you put a pain assessment of “9/10,” you need to document the location, intensity, duration, aggravating and relieving factors in your pain assessment.
I often see nurses who will copy the page from one day to the next. This is a DANGEROUS practice! When you put pen to paper, you really have to think through the patient’s issues and document what you see, smell, touch and hear.
When you go to chart, it is best to think through the patient’s situation and make sure that all your assessments are appropriate rather than just a matter of checking a box. It could save your license and keep you from a malpractice matter. I would love to hear your thoughts and how you think through your charting in the comments below.