Top 6 Charting Tips for Newbie Nurses
The joys of nursing: making a difference, decent pay, and… charting!? Adjusting to your new role is exciting, but there's so much to learn that nursing school just can't teach you — and one big obstacle is learning to chart quickly and effectively.
Learning a new computer system, especially when you've never professionally charted, can be daunting. Time-management and charting skills are hard enough, let alone actually caring for patients. Use these top 6 charting tips to transition into the role and chart like a pro.
1. Have a System
A critical factor in organization and time-management is to have a system for whatever you do. If you go through a literal checklist, you're less likely to miss something — especially as a new nurse. It's hard to chart an entire encounter without missing details, and a personal system helps minimize errors.
Keep this in mind throughout the rest of these tips: developing your personal system is critical. Knowing where you write things down, where you chart things, and in what order keeps you organized in a chaotic environment. Your system should be flexible, since patients and hospitals are unpredictable. With time you'll adjust it to be less task-oriented and more holistic.
2. Write It Down
Something almost every organized nurse does is write down their patient information in some form. You're probably familiar with this from clinicals — but now you're in the big leagues, responsible for your patient, and what you write down matters.
Seeing multiple patients with similar scenarios, it's easy to mix up information. What you write down will be your brain. When a physician asks about your patient, the last thing you want is to not know. Even if it takes 10 seconds to find on your paper, that beats "I don't know" — and staff will respect it.
Many EMRs offer printable "patient care sheets" with demographics, history, ordered medications, and recent labs. That's very helpful, but you need a system: find a specific place to write down what isn't pre-populated. Where's their IV and what gauge? What's their history of present illness? Find consistent spots for this so you can draw accurate information quickly.
3. RTC — Real-Time Chart
This is probably my biggest recommendation: learn to chart in real time. It's one of the key skills that helped me on a telemetry floor and later in the ED. It's easier with a portable computer on wheels, as many units have.
By real-time, I don't mean while the patient is talking — give them your undivided attention. Chart directly after the encounter: exit the room (or stay in), and set aside about 5 minutes to chart what occurred. This accomplishes a few things:
As a new nurse learning a new system, you may not finish the whole chart in 5 minutes — that's okay. Still set aside the time and start with your patient assessment, since that's the hardest to remember later (you'll be doing 5+ assessments). If you don't get to care plans, education, or facility-specific charting, come back when you have downtime. Just keep a checklist of what's left. You'll get quicker with time.
4. Nancy Drew It
Once you know the EMR, you can use it to streamline patient care and your investigation skills. One way is to find information you didn't write down (like you should have). A common example: I'd cross-check my times when I forgot to record when I performed care.
Look for something already charted that relates back to your task. Did you give meds 10 minutes after your assessment? Look into the EMAR, see when the medication was administered, and subtract 10 minutes. Easy enough.
Learning to navigate the EMR quickly helps you gather appropriate patient information. Learn to look back at old labs (6–12 months ago — what exactly is their baseline creatinine?), old medication lists, imported primary-care data, pharmacy info, and H&Ps from previous admissions. Your software will expand or limit this, but every EMR has ways to gather information you'll learn with time.
5. Work Smart!
As a nurse you work hard enough — when you're able, work smart. If your EMR allows, duplicate a previous assessment and adjust what's changed based on your findings. Whether it's your assessment or another nurse's doesn't matter — just make sure the charting reflects your actual assessment. This mainly saves you mouse clicks, but also your valuable time.
Providers have shortcuts too: when writing H&Ps they use "macros" or templates listing a normal review of systems and physical exam, then change what's different. Nurses usually chart in a less convenient way — multiple clicks, checkboxes, and forms — which is convenient for coding, billing, and data mining, but not for nurses. Where the EMR allows duplicating an assessment, you'll save real time. Functionality varies by EMR, facility, and charting-duplication policy.
6. CYA
Nurses are the backbone of healthcare, and the responsibility for a patient's health can trickle down to the RN — which is stressful. A nurse can find themselves in legal trouble if a medical error occurs and they didn't catch it (or worse, caused it).
Given the trend of patients suing hospitals and staff, it's vital to cover yourself with your charting: chart everything that you can. Always document each notification you made to the provider and conversations with the patient/family. Use direct quotes when possible, even if what was said isn't rated PG.
When in Doubt, Escalate & Chart It
If you don't feel comfortable with something, inform your charge nurse or director — and chart it. By initiating the chain of command, you did your duty as the nurse.
Will, these are some great suggestions, not only for “Newbies”, but for those that need a systemized way to document.
Lisa,
Thank you so much! I agree this can be useful for any nurse who has to use electronic charting!
The cheat sheet is not correct. Before is a, after is p
Jess,
Thanks you for pointing that out! I have fixed the error and updated the abbreviation cheat sheet! Thanks for your support!
-Will
I looked this over and agree, great tips. I was concerned when first looking at the abbreviation chart as I see the abbreviation for after and before flipped….. but reading on the site it is correct. Wo
Yes, it has been corrected, thank you! I’m sure there are still some incorrect versions floating around Pinterest unfortunately.
You do not make up abbreviations
Accurate abbreviations should be taught, but if one does not exist and it is just for your own notes and cutting down on time writing – then I’d argue that you can make up whatever abbreviations you would like. To play devil’s advocate, I also think knowing accurate abbreviations is less important now that electronic prescription and charting systems are commonly used, although it is still important regardless!
great site, am looking for information to use to train new grads how to paper chart
Your tips are very helpful for all floor nurses. It is useful for novice nurses and experienced nurses. I am currently working as a travel nurse and we get the worst assignments that nobody else wants. And we also get six to seven patients as well. I think these tips will help nurses get organized so less mistakes will be made. I especially like the real time charting because on a busy unit sometimes we forget things. It is very difficult to get things done especially if you don’t have good time management or team work in a organization.
Thanks for this input.
That’s a great point, I do think these are useful for all nurses! Real-time charting saved my butt when I worked med-surg and ER as a nurse 100%!