A nursing student recently emailed me and asked me, “why are nurses always on the computer?” It seemed like a silly question at first, but then I realized that unless you’re responsible for charting on multiple patients (or if you have students or preceptors, making sure it’s accurate), you don’t really understand all that is required. It’s not like at the end of the shift, you have one big paragraph of information… it’s scattered throughout the chart.
In nursing school, they always teach you the golden rule of nursing.. if it isn’t charted, it isn’t done.
This means that we have to chart absolutely everything. What does everything entail? Seriously. Everything.
I decided to mentally go through my charting and let you know what I’m required to chart on for each patient every single shift. This will slightly vary from hospital to hospital, but not much.
Keep in mind, we have to chart something for all of these. It’s not like if something is normal, we don’t have to say anything.. we have to physically chart something for all things listed below.
All admission documentation must be done… so if the shift before you didn’t have time or forgot, you need to chart:
- The spokesperson/emergency contact and their contact information.
- Any acute or chronic pain: where is it, when did it start, when does it occur, what relieves it, what aggravates it, what medications they take and any other interventions and their response.
- Advance directives and information; if they don’t have any you need to chart that you offered it or that they refused. If they have any advanced directives, you have to obtain them, copy, them, and chart that you did that.
- If they have a portable DNR and/or court-appointed guardian; if so you have to obtain it, copy it, put it in the chart, and chart that you did that.
- If they brought any belongings with them: what they are, where they are, and if something was locked with patient relations and the receipt number
- If they use any devices at home: if they use glasses and what distance they use them to see or if they don’t need any, the same with hearing aids, and walking devices, respiratory devices. If any of those devices were brought to the hospital, you must chart where they are located.
- You must chart if they can bathe themselves, toilet themselves, care for themselves.. if not what do they do and who helps them.
- Functional mobility screening: can they walk independently, does someone help them get in and out of bed/their house?
- Nutrition screening: have they lost weight recently, how much, how are they with swallowing/chewing, how is their appetite, etc.?
- An Ebola screening as well! This is typically 2-3 questions.
- Do they have any religious beliefs we can address?
- We need to offer to call a chaplain or someone for spiritual support.
- If the patient requires blood products, we need to know if they consent to that. If they do not, we need to have them fill out and sign an additional form and flag their chart.
- We must chart if they have any cultural needs we can address
- We must ask these questions: Are you safe at home? Has anyone forced you to have sex? Has anyone hurt or abused you?
- Is this admission related to substance abuse? Do they suffer from chronic pain? Is this admission related to a suicide attempt?
- Where do they live?
- Who do they live with?
- Do they use any outside resources?
- Where will they be discharged to?
- Have they ever stopped taking their medications because they can’t pay for them?
- Is this a readmission within 30 days?
- What medications are they on at home?
- What dose, route, medication is it?
- When was the last time they took it?
- What pharmacy do they use?
- Do they have them here? Where are they right now?
- What’s their medical history?
- What’s their family’s medical history?
- Do they have any medical implants?
- Have they ever had MRSA, VRE, c.diff, or currently have an active infection?
- Did they get their flu shot this year?
- When did they get it?
- Do they want one?
- Do they screen positive for a pneumococcal vaccine?
- Have they ever had one?
- When did they have one?
- Do they want one?
- You need to measure their height and weight (them telling you what it is, you have to measure it)
Now it’s time to start the actual charting…
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- I have to print and interpret a telemetry strip. If they have a rhythm change, I need to print and interpret a new one with each new rhythm.
- Vital signs (heart rate, blood pressure, respiratory rate, pulse oximetry) every 15 minutes (if stable and not on drips then every 30 min – 1 hour).
- Temperature every 4 hours, unless unstable, and source.
- Urine output every two hours (unless indicated more frequently), color and consistency.
- I have to chart that the telemetry monitor is on and that I reviewed it.
- Every time I make a change to the alarm limits, I must chart it.
- The patient’s current level of pain at least every four hours.
- Any interventions to address their pain and their response within 1 hour.
- When I got the report and who I got the report from.
- What kind of an assessment I’m doing (first or reassessment).
- A Glascow Coma Scale.
- The size, shape, and reaction of their pupils.
- A complete neurological assessment at least every two hours, unless they change: chart the exceptions to a normal assessment. If the patient recently received tPA, they get assessed every 15 minutes for a while, then every 3o minutes, then every 1 hour, and finally every 2 hours.
- A complete cardiovascular assessment: chart the exceptions to a normal assessment.
- The heart monitor is on and the limits are set appropriately.
- The current heart rhythm.
- A complete respiratory assessment: chart the exceptions to a normal assessment.
- Where I am monitoring their SpO2 if it’s continuous or intermittent.
- Any supplemental oxygen and device (and appropriate settings).
- Bilateral breath sounds.
- Every time I complete oral, nasal, or endotracheal suctioning I need to chart the amount, consistency, color, their response, and where it came from.
- A complete integumentary assessment: chart the exceptions to a normal assessment.
- With each and every wound, abrasion, incision, etc. I have to chart what it looks like, what the area around it looks like, drainage, color, amount, dressing, condition of the dressing, the last time it was changed, the color of the drainage on the dressing.
- A complete peripheral vascular assessment: chart the exceptions to a normal assessment.
- A complete psychosocial assessment: chart the exceptions to a normal assessment.
- A complete musculoskeletal assessment: chart the exceptions to a normal assessment.
- A complete musculoskeletal assessment: chart the exceptions to a normal assessment.
- Every time they have a bowel movement, I have to chart the color, consistency, and amount.
- Every time they’re nauseated or constipated, I have to chart what precipitated it, what I did to intervene, and their response.
- A complete genitourinary assessment: chart the exceptions to a normal assessment.
- A Braden Scale / Skin Assessment.
- A Morse Fall Risk Assessment.
- Any and all precautions (fall, bleeding, suicide, swallowing, seizure).
- If I updated any family members or if any are at the bedside.
- What I’m doing to prevent VTE (if I have an order, what the order is, if it’s in place, if it’s been initiated, if they have screened positive).
- Every time I give a medication, I scan it and ensure it’s the right dose, route, patient, med, time.
- If it’s a pain medication, I have to chart what pain assessment I’m using, their score and what part of their body is hurting.
- I have to chart a follow-up pain assessment with the above-mentioned items within one hour of administration.
- For all continuous drips, I chart the appropriate rate and titrate as needed.
- I chart and make sure every ML of fluid coming in and going out of their body is accounted for. This includes oral and intravenous medications and anything the patient has voided, vomited, or defecate. I ensure the totals at the end of the shift are appropriate.
- For every single IV, I chart what it looks like, what the dressing looks like, what is going through each lumen, if it’s clamped or infusing if I changed the dressing when it’s due to be changed. If I discontinue an IV I have to chart it and their response and if I started a new IV I have to chart the size needle, the date, the time, the location, their response, the prep I used, if there was blood return, what the dressing looks like and how I secured it.
- If the patient is on multiple IV medications, I have to chart which lumen the medication is infusing into after I ensure it’s compatible with anything else also infusing into the same lumen.
- I have to chart hourly rounding, the number of side rails is up, what armbands their wearing.
- Every two hours I must chart that they were turned.
- Every time they are cleaned and what was cleaned (peri care, oral care, changed the linens, the bed pad, washed their hair, wiped their face.
- If they are restrained, I have to chart why they’re restrained, what I did to prevent the need for restraints, what I’m doing to get rid of the restraints, who I educated about it, what I did and what the patient did when I released them every two hours.
Basically, absolutely anything that you do, you have to write down that you did it. It’s incredibility time-consuming. So, if you called a patient’s family.. you have to chart it. If you helped them to the bathroom, you have to chart it. Every time you flush their IV, every time you change the cap on their IV, etc.
Oh, and let’s not forget about patient education and their care plans…
- I have to open appropriate care plans and chart on them every shift. I have to say if they are meeting the outlined goals if they’re progressing or not and type out why.
- I have to open appropriate educational topics and chart on them every shift. I have to chart who I talked to, their readiness to learn, how I educated them, and their response.
- This is after I’ve identified the primary learner, their preferred language, their preferred learning style, and if there are any barriers to learning.
- I have to check every single order the physician has entered to ensure it’s appropriately ordered and appropriate for the patient.
- I have to make sure all quality measure was met and documented appropriately.
- I have to check all of their labs, ensure they were completed appropriately and if they’re out of range I have to know and understand why and notify the physician as appropriate
- If the patient has a central venous catheter, restraints, or a urinary catheter, I have to chart why.
Keep in mind, this is all we have to chart IF NOTHING CHANGES. If a patient isn’t doing so hot, we have still had to chart the above-mentioned items. We just have to chart a lot more about what happened, what we did about it, who we notified, when we notified, the MD’s response, and the patient’s response.
If a lab value comes back critically high or low, we have to chart who collected it, when they collected it, the lab test, the value, who we paged, what time we paged, what time they responded, any orders we received.
You can imagine why it’s so difficult for a hospital to implement a new charting system. And, believe it or not, not only is the nursing staff responsible for charting all of the above on every patient, but many nurses also take classes so that when the physician needs help charting, they know how to help them as well.
So, the next time a physician gets mad at you for all that they have to chart or the computer not working.. please show them this as you help them.
More Resources for Why Nurses are Always on the Computer:
Nursing Notes the Easy Way: 100+ Common Nursing Documentation and Communication TemplatesChart Smart: The A-to-Z Guide to Better Nursing DocumentationCharting: An Incredibly Easy! Pocket Guide (Incredibly Easy! Series®)DocuNotes: Clinical Pocket Guide to Effective ChartingRNotes®: Nurse’s Clinical Pocket GuideImproving Nursing Documentation and Reducing RiskNurse Charting Notebook