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The secret of successful charting

doctor-nurse-and-chartDespite a wealth of technological advances, we all still spend more time charting than we’d like. But what if you looked at charting as something other than a chore?

Instead of seeing it as one more thing to cross off your to-do list, what if you considered it a vital means of communication? After all, isn’t that the original purpose of charting?

In this four-part series (scroll to the end for the rest of the articles!), Dr. Brady and Nurse Rebekah explain the secret of charting the right way: It’s called “conspiring.” And conspiring with your colleagues can improve patient care, make the doctors happy, and keep you out of court.

Dr. Brady: No, I’m not planning on writing a book called The ER Conspiracy. The books I write are actually all about doing your job better. In fact, by “conspire” I don’t mean the first definition in Merriam-Webster’s dictionary, which is to scheme or plot, but rather the second, which is more true to the verb’s etymology: from the Anglo-French conspirer, from the Latin conspirare, to be in harmony; conspire, from con = together + spirare = to breathe. The second definition is “To act in harmony toward a common end.” People, I just want us all to be in harmony and “breathe together.”

In medicine, we need to conspire or collaborate more. When different healthcare providers act together in harmony, patients will more likely be satisfied, rather than confused—and if something goes wrong and we all end up in court together, we’ll be less likely to have helped the plaintiff’s attorney.

Why will patients be more satisfied? The reason is simple. If everyone tells a patient something different, she doesn’t know whom to trust and gets confused.

Here’s an example. A patient comes in with cough and shortness of breath. The ER nurse does her assessment and tells the patient it’s probably a virus, but that she needs a chest x-ray to be sure. Then the ER doctor comes in, does her assessment and tells the patient it’s probably a virus and she doesn’t need a chest x-ray or any antibiotics.

Two days later, she’s not better and goes to her doctor, who tells her she has bronchitis but doesn’t need an x-ray, and writes her a prescription for antibiotics. If she’s in the top fifth percentile for IQ, she’ll probably realize that differences of opinion are not uncommon in certain conditions. If she’s like the other 95 percent of your patients, she’ll probably be confused and assume that two of the three people who gave her advice are incompetent. If only everyone had acted in harmony, the patient might have instead been satisfied and content while the virus ran its course and she recovered completely.

Nurse Rebekah: Most of us want to be the expert at something in our lives. Some people just pretend like they’re experts on everything—which we all know is totally implausible. (My hubby calls these people “Mr. SMITH,” which stands for Smartest Man In The Hemisphere. Try that on your next know-it-all…it’s hilarious.) But many people spend the majority of their lives honing their craft, knowledge and career. Whether you’re a working nurse or doctor, a Starbucks employee or an electrician, at some point you’ll probably know more than other people who may or may not be in your field, and your advice will be sought out. Therefore, because people are seeking your advice, you should make sure you know what you’re talking about—and if you DON’T know what you’re talking about, heed my mother’s advice to “keep your pie hole shut.”

I say this because patients look to us for guidance about their health. Sure, they may have had a prior appointment with Dr. Google, but they’re looking for your professional opinion. Stick to the facts. Using Dr. Brady’s example, I might say, “Mrs. Smith, because of your cough and fever, I’m going to order a chest x-ray per our protocol to expedite your care in the emergency room. The doctor will look at it and tell you what he thinks.” Leave it at that. Don’t claim virus or bacteria—because unless you brought your microscope with you, you won’t be able to defend that claim. And the physician should have the foresight to look in the chart and not say, “Oh, I don’t need a chest x-ray…why did that silly nurse order that?” Don’t staff-split. Leave that to the psych patients and four-year-olds.

Starting to get the idea? Only say—and write—exactly what you observe. Anything more is just speculation and can confuse and frustrate both patients and staff.

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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  1. Pingback: Tips for nurses on having more ENERGY! | INTERNATIONAL NURSES ASSOCIATION