Charting in nursing is the systematic and standardized process of recording a patient’s health status, the care provided, and their response to treatment, forming a permanent part of the medical record. This documentation is a fundamental component of the nursing process, ensuring a comprehensive and accurate history of the patient’s journey is created. It is a professional responsibility that translates hands-on care into a universally accessible format. The practice of charting is designed to be a continuous, chronological account, capturing everything from initial assessments to discharge planning. Accurate record-keeping is the foundation upon which safe, high-quality, and evidence-based patient care is built across all healthcare settings.
The Essential Purposes of Nursing Charting
Nursing charting serves multiple functions, primarily facilitating clear communication among the entire interprofessional healthcare team. The chart acts as a central hub of information, allowing physicians, specialists, therapists, and other nurses to quickly understand the patient’s current status and the plan of care. This shared record ensures that care remains coordinated and continuous, preventing errors or duplication of efforts across different shifts or departments.
The patient’s chart is also a formal, legal document that provides evidence of the care delivered or omitted. This record is subject to review by regulatory agencies, insurance providers, and legal entities, offering protection to both the patient and the healthcare facility in the event of litigation. For a note to hold up legally, it must be accurate, timely, and objective, reflecting only the facts and the nurse’s professional observations.
Documented data is used for quality assurance activities and research. Auditing patient records helps facilities monitor and evaluate the standard of care being provided, identify trends, and implement improvements to protocols. Furthermore, this aggregated data supports medical research and is necessary for billing and reimbursement from insurance companies and government payers.
What Information Nurses Record
Nurses are responsible for documenting data points that track the patient’s physical and emotional state. This begins with a detailed record of the patient’s status, including objective data like vital signs, physical examination findings, and input/output measurements. Subjective data, such as a patient’s description of their symptoms or pain level, is also recorded, often using the patient’s own words in quotation marks.
The documentation must also precisely detail all nursing interventions and treatments performed. This includes procedures like wound care, positioning changes, and the application of assistive devices. The patient’s response to these actions must be noted, such as a decrease in pain after a medication is given or a change in oxygen saturation following a respiratory treatment.
Medication administration is another area requiring careful charting. The nurse confirms and documents the “five rights” (right patient, drug, dose, route, and time) before entry. Following administration, the nurse must chart the patient’s reaction, noting any side effects or the desired therapeutic effect. Finally, all patient and family education provided, along with the patient’s demonstrated understanding of discharge instructions, is recorded to support a safe transition out of the facility.
Different Methods of Documentation
The physical system for documentation has largely shifted to the Electronic Health Record (EHR), which uses computer-based programs to manage and store patient data. EHRs offer benefits like improved accessibility across different care settings, enhanced standardization of data entry, and automated data capture from monitoring equipment. The underlying structure of the nursing note relies on specific organizational frameworks.
One common method is the problem-oriented approach, which organizes documentation around a patient’s specific health issues. The SOAPIE format is a structured example, breaking down the note into:
- Subjective data
- Objective data
- Assessment
- Plan
- Intervention
- Evaluation
Another structured style is Focus Charting, which uses the Data, Action, and Response (DAR) format to concentrate on a patient concern, the nurse’s immediate action, and the outcome of that action. Narrative charting, a more traditional method, involves a chronological, paragraph-style account of the patient’s day. Charting by Exception is a condensed method where the nurse only documents findings that deviate from pre-established norms or standards. These methods ensure the documentation is organized and comprehensive for every member of the care team.