Writing in the Field

Writing in the Field: The Three Kinds of Charting

Most charting completed by nurses falls into one of three categories: 1) flowcharts; 2) careplans; and 3) narratives. Individual employers require different amounts of charting in these areas, (insert example here). The guidelines below are intended to be broad enough to cover many different levels of charting while still providing useful suggestions.

Flowcharts

Although flowcharts are a part of nearly every medical service provider’s record keeping, the systems themselves are different enough between companies, and the skills required far enough from the writing process that this aspect of charting will not be covered here.

Careplans

The careplan consists of three parts: 1) definition of the problem; 2) interventions and/or solutions; and 3) evaluation of the relative success of the interventions and solutions.

Nursing diagnoses are NOT medical diagnoses.

The diagnosis given by a doctor and the one acted on by a nurse are two different things. Example: A medical diagnosis is “Diabetes Mellitus,” while a related nursing diagnosis would be “risk for unstable blood glucose.” The first example is the doctor’s diagnosis of the patient, the second suggests a course of action to the nurse; you must work to reduce the risk.

Interventions and solutions must be specific to each patient.

Patient age, relative health, complicating factors and recovery range must all be considered when devising new interventions. Example: “Patient to check blood sugar 4 times, daily.” This may work for many patients, but if the patient is unable to check their own blood sugar (patient under the age of 5, patient physically impaired, patient has Alzheimer’s), this intervention is unrealistic and must be changed.

Evaluations must be measurable.

When writing the evaluation you must include a definite time frame and some measurable quantity to determine effectiveness. Example: “Patient will maintain blood-sugar levels between 80 and 120 x 2 weeks.” This provides both a measurable goal and a time frame for determining success.

Narratives

Narratives are an important part of nursing communication and important components of capturing a patient's history and treatment.

Use only standard abbreviations.

Different facilities and even licensing agencies have standard lists of abbreviations. Make sure you know these standard abbreviations and resist the impulse to come up with your own, even if the meaning of the abbreviation seems obvious to you. Deviation from those accepted forms can cause confusion in your narrative and can even get you in legal trouble.

Do not use the first person.

In narrative charting, avoid the use of “I” and “me.” Instead of “I observed . . .” use “This nurse observed . . .” “I change the dressing daily,” becomes “Nursing changes the dressing daily.” This helps to maintain the impersonal tone discussed above.

Record communication with others.

Nursing never occurs in a vacuum. Your communications with doctors, therapists, other nurses, patients and their families regarding the patient’s health should be noted in your narrative, especially if such conversations result in or are pursuant to changes in patient care. Recording this communication allows readers of your narrative to track changes and establish clear lines of cause and effect.