8 Useful Tips to Improve a Nurse Charting Cheat Sheet

Registered nurses value charting cheat sheets and use them as a go-to tool in exercising best practices for nursing documentation. Recording in maintaining the details of patient care, welfare, and recovery, nursing cheat sheets aid with thorough examples of sequential steps to be followed.

Initially, nurses may not feel it is crucial as there is very little stress given in most programs about the importance of documentation and compliance requirements to follow when recording patient details.

However, when a specific ailment is encountered for the first time then it helps the nurse through the patient’s care. For instance, a completely new patient may not realize the importance of hydration in severe diarrhea, but with a reference to the nursing electrolytes cheat sheet, one can easily assist the patient back to recovery.

Need for proper nursing charts and cheat sheets

• High-ticket demand

Nurses deal with numerous patients, and the nursing documentation needs to rise with every new admission. There is a huge amount of patient data to be updated and maintained regularly. Most nurses take several years to develop a nursing cheat sheet of their own that works like a well-oiled machine.

• Inadequate training

Some schools do not prepare nurses enough with nurse charting and patient documentation training, which is problematic specifically for new nurses on the job who frequently struggle with tasks.

• Accurate record maintenance

Nursing documentation offers precise data on each medical treatment given to a patient. Healthcare facilities need to comply with sufficient paperwork to prove that the right care was given as per the regulations and laws of the land. In case of an official complaint by a patient, nursing documentation is a handy tool for all the key information detailing the treatment course during a nurse’s shift.

• Quick reference for care providers

The doctors who are seeing the patient after an interval can refer back to the documentation to see the progress of the recovery. It provides essential clinical information to the care providers enabling them to make accurate choices for patient safety. Without documentation, it is not possible to access the right patient data or have any inkling about the treatments already administered to the patient.

After understanding the importance of nursing documentation, if you are looking for tips to maintain nursing charting cheat sheets, check here:

1.Follow HIPPA compliance

One important point of HIPPA compliance is the safety and integrity of patient data. So ensure that you don’t randomly write patients’ names and or their details in the notes. At the end of the shift, after you have recorded the information in the treatment plan, remember to shred your notes.

2.Prioritize documentation

Even on a busy day, it is recommended that a nurse does not push the documentation till the end of the shift. One tends to forget what was done at the start of the shift and may not record trivial information that will prove to be critical at a later stage and may result in gross negligence on clinical grounds. Senior nurses always follow the rule to document on the fly. It is as important as moving on to the next patient in line.

3Legible and grammatically correct

It is important to document for future reference by some other nurse or doctor. So it is important to write your notes in legible handwriting, a readable language without any slang or short words, or grammatical mistakes.

4.Use Digital tools

Several templates and tools can aid in nursing documentation as per the charting and cheat sheets. You can use these tools to record the information. The advantage of using automated software to record data eliminates spelling and grammar mistakes. If you use charting software, you can turn on the notifications for any important changes in the patient’s data that will be useful for care delivery.

5.Chart in real-time

It is a bad idea to chart in advance as one may need to strike out information that will still be available for the record. So, it reflects upon the nurse as a bad practice of her workflow for documentation. Even late entering and corrections should be avoided and charting has to be finished at least for important aspects in real-time. One can use tabs to record all the information in a template in current times of technology.

6.Objective points

Any charting notes have to specify the facts objectively. It should never record the opinion of the nurse. Nurses can use these notes at a later stage for the learning curve, but the documentation as such should be free of any influential matter from the nurses’ side.

7.Within normal limits

Understandably, a few days are crazy in terms of the number of patients that warrant a nurse’s attention. On such days also it is important to record the information that is WNL or within normal limits. Once the nurse has some space and time in her schedule, they can finish the report.

8.Forward-thinking

Only a nurse can understand what it is like being one. So if you come into a shift and find all the patients’ charts are haphazard or incomplete, you have a lot on your plate for the day. Likewise, if you don’t write down the details meticulously for the next nurse to comprehend, then it will be difficult for the next shift nurse who will replace you.

It is also important to note details like patient education and family interaction in the course of your shift.

Conclusion:

Healthcare institutions must follow standards for nursing paperwork for regulatory compliance with federal and state laws. It is necessary to record either in nursing software or alternative approved methods to record documentation relating to patient care and nursing assessments.

Any new treatments and drugs used in the course must be entered into the patient’s clinical records. This step is necessary to provide a base for the caregiver in charge to look into a patient’s history and medical background and avoid medical malpractice or negligence. So, it pays for budding nurses to do their groundwork and take training for documenting correctly using charting and cheat sheets.