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How to choose the right words when charting

nurse-charting

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In Parts I through III of our Charting essentials series (scroll down for all the links), Dr. Brady and Nurse Rebekah discussed the importance of charting as a means of communication. Now, they encourage you to choose your words carefully.

Dr. Brady: Before you chart something that may be critical, consider conspiring with the rest of your team. I’m not saying you should lie. You are obligated to tell the truth, but you get to decide how you will tell the truth. If you and the doctor think your patient with a URI and chest pain may actually have a pulmonary embolism, chart “pleuritic chest pain” and the CT scan is justified—and if there is a complication from the contrast, everyone is vindicated.

If, like most people with a URI and chest pain, she really has just a painful cough, chart “painful cough” instead of “pleuritic chest pain” and send her home. If three months later she really does have a blood clot and you all land in court, the consistent, harmonious charting will likely get the case dropped.

One more example: If a mom says her child is lethargic, but the child looks fine, chart “less playful” rather than “lethargic.” That’s what the mom means. She doesn’t mean “I can’t keep my child awake,” which is the medical definition of lethargy.

Again, you shouldn’t lie, but if you spend a little time conspiring or collaborating with the doctor and explaining things to your patient, you might accomplish many things that would make both your mother and President Obama proud: less unnecessary testing, lower medical costs, more realistic patient expectations, few medicolegal lawsuits and hopefully happier, healthier and more trusting patients. Perhaps if we are breathing in harmony, work could even become more harmonious.

Nurse Rebekah: Harmonious! Sounds like yoga to me! Relaxing and very zen-like. However, when it comes to charting and documentation, I just try to be as objective as possible. For instance: “Patient complains of severe nausea and is currently eating chips in triage.” That uses the patient’s own words but paints a pretty clear (and objective) picture of what is really going on.

Try at all costs to take the bias out of your charting. If your chart looks biased, a lawyer can always say to a jury, “Look, Nurse Child wrote that this patient stank and was rude. She didn’t even like this patient, so how could she have taken good care of him?” That will make you look like Nurse Ratched.

Instead, you can always chart: “Patient stood up on gurney and urinated into sink while calling staff ‘ugly, stupid, dirty gigolos.’” The patient just painted his own picture as a real jerk.

Healthy work environments and healthy communication styles go hand in hand. In the super technology-laden world that we live and work in today, we can take care of many, many patients, all at the same time. This can come at the expense of face time with our colleagues. So strike a downward-dog pose, breathe and collaborate. Maybe even light a candle to relax as you conspire away.

Got it? Conspiring with your colleagues is a good thing. So choose your words carefully, communicate your concerns and expect an increasingly harmonious environment.

The Essentials of Nurse Charting

Part 1: The Secret of Successful Charting

Part 2: The One Thing Nurses Should Never Assume About Charting

Part 3: How to Avoid Lawsuits with Charting

Part 4: How to Choose the Right Words When Charting

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Brady Pregerson, MD

Brady Pregerson, MD, a returned Peace Corps volunteer and winner of the 1995 Wise Preventive Medicine Scholarship, completed his medical school at the University of California, San Diego, and his residency at Los Angeles County General Hospital. He has authored three medical pocket books for nurses and doctors, as well as the educational web sites erpocketbooks.com and gotsafety.org. Dr. Pregerson currently works as an emergency physician in Southern California. He writes, "Although the ED environment may be quite different from working on the hospital floor or in an office setting, I am hopeful that you can take these tips and apply them to your own specific work situation." You can buy his books on lessons from the ER, including Don't Try This At Home: Lessons from the Emergency Department and Think Twice: More Lessons from the ER, at amazon.com.
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2 Responses to How to choose the right words when charting

  1. K Bennett

    We don’t use narrative charting where I work anymore. We have a computer program where we just click under topics and headings to chart…It’s actually difficult to find a particular “ailment” a lot of times too.

    • nursebetty12

      Although computer charting is becoming the “norm” in most facilities and narrative paper charting is going by the wayside, the “click & go” is by far no way to chart & is a very poor way to communicate the status of any patient.
      No matter what system you use, we have Epic & it is NOT ER driven & is quite poor compared to other systems I’ve used, if any health care worker-RN, MD, RT, PA, NP, etc- relied solely on the templates provided we would be in big trouble in court. There is ALWAYS room for a narrative note & no patient should be without one. If we all rely on Templates, we will one day potentially find ourselves in court for one reason or another and if lucky to remember anything about the patient based on boxes that were “clicked” we will still lack important clinical information needed to truly describe the pt clinical presentation, quotes stated regarding to such as well as other provider input. Anyone can click a box, but what does that say about the care you provided? Was it also minimal just like the template? If you find yourself as a part of a lawsuit you will wish the few extra minutes of documentation would have been done… Right before you settle that malpractice suit with a big fat check!

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