Do’s to Good Charting in Patient’s Medical Record

Posted by: Rey-Ryan Mapiles RN

Do’s to good charting
1. Check to be sure you have the correct chart before you begin writing
2. Make sure your documentation reflects the nursing process and your professional capabilities.
3. Write LEGIBLY
4. Use a permanent black ink pen ( other colors do not Xerox well)
5. Chart completely
6. Be concise and accurate
7. Chart time for each entry
8. Document PRN medications and exceptional things in the record.
9. Chart precautions or preventative measures, ( Such as use of side rails)
10. Include the following for procedures: what was done, when it was done, who did it, how it
was done, how the client tolerated it, adverse reactions, if any. Paint a clear picture of what
happens.
11. Record each phone call to or from a physician, including exact time, message, and response.
12. Chart when a doctor makes a visit, and if there are any new orders.
13. Chart as soon as possible after providing care.
14. Chart a client’s refusal of treatment or medications.
15. Chart client’s subjective data.. ( what he says and how he says it) use quotations if necessary.
16. If you remember something important after you have completed your documentation, write
“ late entry” and make the note.
17. If information on a flow sheet does not pertain to your patient, write N/A for not applicable,
leaving it blank appears that it was not addressed or an oversight.

Nursebitz.com Alert: Make sure that each page has the patients name on it. Just last name is not acceptable, as it could become misplaced, and posted on the wrong chart of someone else with the same last name. These good rules of charting is a good start to successful documentation.