Guidelines to Charting Flashcards
If you chart that you noticed a problem, you should follow up with what you did to address the problem
Document what you did and the outcome
try to be time. don’t wait until last minute to do your charting, especially if more than one person is charting on the patient
chart right away
student - report what you chart
be factual. use quotes if you need to
what ever patient states, put in “quotes”
pt states “I have pain”
read your notes. if you had to leave in an instant and couldn’t give report, would the next nurse be able to assume care with little to no question
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use correction terminology and check your spelling
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Do not leave blanks
if blank, put line through blank space
do not chart in advance, your patient will change, guaranteed
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DO NOT CHART FOR SOMEONE ELSE
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do not alter a record to say something else
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if you make a mistake, one line through the entry, write error and sign it
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do not black it out. no white out
looks like you’re trying to cover something up
no pencil
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