Charting or the act of writing down all that has happened on your shift is central to the very core of nursing.
The old saying goes “If you didn’t chart it, you didn’t do it.”
How else is any nurse or doctor who is coming after you going to know what you did?
I’ve used all kinds of charting.
In my first hospital there was a hybrid charting.
We had checklists that we used from our nursing care plans to plan the care for the patient.
We had the very beginning of computer charting.
This was 2001, a very long time in computers ago.
The computers were practically a typewriter with a screen.
We were to do the checklists and a narrative chart note on each patient.
When I went to the OR, the charting was all done on a three fold form, which had a duplicate page.
When I participated as a SME (subject matter expert) when my current organization was working with EPIC to create our EMR, I had to learn computer charting with EPIC.
It is basically a three fold form with check-boxes that are sent in real time to the server farms for saving.
The point is charting is a big deal.
Everything we do as nurse has to be charted, in some form, as proof we did what we did.
The thing about charting is you can be as brief or as long-winded as you want to be.
I had a conversation with the nurses I was relieving tonight.
The primary nurse handed me the card with the written time that the throat pack went in.
I thanked her.
The secondary nurse, who had been acting as a scrub, asked me about it.
The primary nurse and I agreed that we chart the insertion of the throat pack and the removal.
The secondary nurse asked us why.
The field needed my attention at that moment and I texted her later, ‘If you were, God forbid, called to testify about the throat pack being left in you absolutely want documentation.’
If only the insertion is charted, did you really pull it out if not charted?
At its core, charting is about how much liability you are comfortable with.