David Morrison, RN

I have always maintained that nursing is nursing is nursing—meaning simply that whether I'm practicing nursing in a large university setting or a small rural hospital, the nursing care I deliver to my patients will remain the same. What will change is the way I document the care I deliver.

Going from hospital to hospital as a traveler, you will encounter some facilities that have mastered the art of efficiency in nursing documentation. You will also see quite a few that still rely on archaic methods that often have you double- or even triple-charting your patients' information. Others might swing to the opposite side of the spectrum and only require minimal charting that leaves you wondering how they ever pass a Joint Commission inspection. Regardless of the system they have in place, you must always be sure you document the information that is reflective of your care.

The way most of us learned how to chart in nursing school was with good old-fashioned paper and pen. Although this method is being phased out at many facilities, I believe we still have quite a few years before everything is electronic.

Some facilities have tried to streamline paper-and-pen charting by using "charting by exception." This can mean that if a patient meets a set criteria, your charting might be as simple as checking a few boxes. For example, a check mark placed in a box at 0800 in the pulmonary section could mean that your pulmonary assessment of your patient revealed that the lungs were clear, respirations were regular and non-labored, and no supplemental oxygen was being used. If your patient deviated from any of the criteria, however, you would need to place an "X" in the box and document the deviation in the nurse's notes.

When charting by exception, you must always know precisely what you are indicating by using symbols or checking a box. If the criteria are not stated on your nursing flow sheet, you must ask for some type of key that lets you know exactly what you are charting. If in doubt, you may have to chart in narrative on your nurse's notes.

Computerized charting

Many facilities are now adopting computerized charting as their means of recording patient care. If you do not yet consider yourself "computer literate," you might want to take a class—because this is definitely the wave of the future.

I have worked at many facilities with computerized charting, and I've found some systems that streamline your work and some that only add to it. The best systems allow some sort of "copy forward" option that will allow you to chart redundant information quickly (for things that do not change often, such as IV site locations).

Many aspects of your nursing care will have certain sections or tabs where information needs to be charted. If you know ahead of time that the facility uses computerized charting, be sure that you have a computer class scheduled during your week of orientation.