Elevating Documentation: Importance of Quality Nurse Charting Notes in 2024

The Hows and Whys of Nursing Charting

Information is king in healthcare. Breathing rate, blood pressure, and skin color can tell much about a patient's health, with lab work and X-rays providing even more details. Patients' information is charted—or taken and laid out in a particular format—to ensure that different medical staff can understand it no matter their shift.

Today's article covers nurse charting, as nurses see patients the most, especially in hospitals. We discuss charting's importance, the advantages of using electronic medical records when charting or notetaking, and why medical-grade computers are best for this essential task.

Importance of Nursing Charting

Nurse charting, often referred to simply as charting, plays a crucial role in documenting essential patient information within their medical records. The term "required" encompasses various legal, professional, and institution-specific guidelines. This documentation typically includes vital patient statistics, prescribed medications, and details regarding medical procedures, among other important information. Proper charting ensures healthcare providers have accurate and comprehensive data to inform their care decisions.

Nurses don't draw up a new medical chart at each patient visit; instead, they update the patient's existing one with the latest information, a critical factor in creating a robust medical record for each patient.

Nurse charting isn't an afterthought or some mindless paper-pushing. Effective documentation can:

Contribute to patient continuity of care: In brief, what is the quality of the patient's care over time? Were they diagnosed correctly? What was their food during each mealtime? What were their medicine dosages? All these details must be organized, coordinated, and documented between nurses, providers, and other medical staff.

Communicate care goals: What is the overall care plan for this patient? Charting can provide answers, especially in the nurses' notes section of the medical record.

Reimburse insurance claims: Nurse charting records billable services and their rationale for insurance companies or other payers.

Provide legal protection: In the event of a lawsuit, the medical records created by charting provide documented evidence of the nurse's exact involvement with that patient's care.

Demonstrate nurse competency: Professional regulators, from the nurse's college to licensing boards, can review nurses' Subjective, Objective, Assessment and Plan (SOAP) notes and any other nursing notes on the electronic medical record (EMR) system to assess their knowledge, skill, judgment, and safe practice.

Provide data for quality improvement: Projects to improve healthcare, like switching from paper patient records to EMR, may include reviewing medical charts to understand the care process.

Advantages of Nurse Charting with EMR

In the past, nurse charting was performed using paper charts and files to monitor patients' conditions. Everything was handwritten, including patient information and nursing notes.

The digital transformation of healthcare has replaced paper with electronic medical records (EMRs) for nurse charting. The advantages of this shift are numerous:

Speed: Nurse charting can be done faster and more accurately on a keyboard or touchscreen than by hand.

Standard form: The fields in an Electronic Medical Record (EMR) system present a comprehensive overview of essential patient information clearly and organized. This includes critical details such as the patient's full name, a complete list of current medications—including dosages and frequencies—and the tailored treatment plan for their specific health needs. During the charting process, EMRs provide valuable alerts to nursing staff, flagging any gaps in the documentation or raising questions regarding particular entries, such as potential discrepancies in medication dosages or missing patient assessments. This functionality ensures that healthcare providers maintain a high standard of care by minimizing the risk of errors and enhancing the overall efficiency of patient management.

Shareability: In the past, patient paper records had to be photocopied and sent to all participants via fax or mail. Today, EMRs allow multiple medical personnel to look at the patient's information simultaneously.

Point of Care: Nurse charting can be entered right at the patient's side through an All-in-One medical computer or medical tablet. There is no more hassle retrieving the correct files from the nurses' station or re-entering the information into a stationary computer later in the shift.

Traceability: EMRs automatically date and time each entry from nurse charting and identify electronic deletions. This feature aids in circumstances like tracing unusual patient symptoms and legal investigations.

Protect patient privacy: To adhere to HIPAA regulations, medical computers are equipped with a variety of security features, including RFID identification and Imprivata Single Sign-On, or SSO. These advanced measures are designed to protect the integrity of nurses' input during charting, ensuring that sensitive information remains secure across the healthcare network.

Greater and consistent accuracy: Built-in barcode scanners and RFID readers in medical computers can make important yet tedious tasks like patient and drug identification during nurse charting easy and with minimal error.

Nurse Charting Done Right with Cybernet Computers

Nurse charting effectively documents today's care. It is an important task that offers many benefits, primarily through EMR systems.

In modern healthcare, most nurse charting uses electronic medical records (EMRs). If you are seeking an appropriate medical computer to support your EMR system, consider contacting the Cybernet Manufacturing team. They can provide detailed information about their lineup of medical computers, which includes essential features such as medical grade certification, fanless designs for quiet operation, and sealed IP65 front bezels for enhanced durability and cleanliness. Their knowledge is ready to assist you in finding the right solution tailored to your needs.

Do you need help finding exactly what you need? Cybernet is an Original Equipment and Design Manufacturer. We ultimately control every aspect of our products, such as network options and privacy screen protection. When charting, we can develop the configuration that's just right for your nursing staff.