In This Episode
I’m going to go over important charting tips for nurses. Whether you’re a new nurse or a seasoned nurse, we’re confident you’ll find something from this list that will help you in your nursing career. You can find the show notes for this episode on nursemoneytalk.com/podcast/11.
Charting Tips for Nurses
- Think Like a Lawyer
- Stop Double Charting
- Avoid Inconsistent Charting
- Document Events As They Happen
- Keep Paper Handy to Jot Down Notes
- Avoid Charting Ahead of Time
- Avoid Emotional or Opinionated Charting
- Trying to Pass off Chicken Scratches as Handwriting
- Using Fun Color Ink Pens
- Making up your own Abbreviations
- Not Following HIPAA Guidelines
- Charting in the Wrong Patient’s Chart
- Rambling On and Not Being Concise
- Erasing Patient Charts
- Altering Patient Charts
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Please note: Some of the resources below may be affiliate links. If you click and make a purchase, I may receive a commission. For more info, please see my disclaimer.
- 15 Not-So-Obvious Documentation & Charting Tips for Nurses (Article)
- If you need a refresher on what the current Joint Commission approved abbreviations are…you can check it out at the Joint Commission website.
- If you’re looking for some good pens to use on your shift, I recommend Pilot pens (Amazon).
- Full size black folding nursing clipboard
- Lightweight aluminum construction
- HIPAA compliant design to hold sensitive patient documents
- If you’re searching for a foldable clipboard, go check this out on Amazon.com.