March, 1978 – 11:30 p.m.
I had just finished walking rounds with the night shift nurse, clocked out, and sat down beside the chart rack to begin my charting before I could go home. I usually was able to complete some of my assigned five patient charts during my shift, but it had been nonstop all evening so I barely had time to gulp down my dinner. Each nurse was assigned five charts and must chart on two of the patient problems before going home. We were not paid overtime to complete our charting. We used the S-O-A-P format.
O is for objective – what you observe.
A is for assessment.
P is for plan.
I took the heavy 3 inch thick chart and turned to the tab marked “Nurses Notes”. I took out my blue inked pen and began. Day shift charted in black ink, evening shift used blue ink, and night shift used red ink. I remembered my college instructor’s words about charting.
“If it’s not charted, it’s not done. Try to paint a concise picture with words of exactly what you did. If you are ever sued, you likely won’t remember the patient several years from now. The lawyers and jury will scrutinize your every word.”
Mrs. K. in Room 515 had had a below the knee amputation two days previously. I scanned her problem list and chose Pain and Diabetes from her list. I began writing using approved abbreviations:
S: c/o moderate RLE pain. (complains of moderate right lower extremity pain)
O: RLE incision intact. Moderate swelling, slight erythema. VS (vital signs): 99.2-76-18-136/84. (temperature-pulse-respiratory rate-blood pressure)
WBC (white blood cell count) 7.4. Given 2 Percocet.
A: Moderate post-op pain. Pain relieved with Percocet. No sign of infection.
P: Continue to monitor incision qs (every shift), medicate for pain prn (as needed). Instruct pt (patient) about phantom pain.
I completed my last chart at midnight, put on my coat, and drove wearily home through the black night.
Reflection – 2014
Charting has changed over the years, but the saying of my instructor still holds true in the litigious American society, “If it isn’t charted, it isn’t done.” After Xerox copies were invented, we switched to black ink for charting so the charts were more legible when copies were made.
In labor and delivery, we had to write our initials and time on the fetal monitor strip whenever we entered the mother’s room, and whenever we gave any medication or did a procedure. When I was a visiting nurse in the 1990’s, we used a check list system for the daily visits and left a carbon copy in the home for the next nurse. When I worked in the nursing home as a nurse practitioner, we had a dictation service with secretaries which worked very well. We returned once again to the S-O-A-P format.
In my current job, we have an electronic patient record and no more paper charts. I have machine dictation which is only about 70% accurate, so it takes quite awhile to correct all the mistakes. But at least you can read everyone’s notes and never have to go hunting for lost charts. However, when the computer system crashes, it shuts down the whole system because we have no access to the patient records. Thankfully, that doesn’t happen often.
I recently called a doctor’s office to request a copy of a patient’s records. His assistant said she would fax them over, but warned me we would not be able to read his handwriting! Over the years, I’m afraid my handwriting has deteriorated also as I have spent countless hours writing in patient charts. Charting isn’t the most satisfying part of nursing, but it is necessary for communication and a required part of my job, so I try to do it thoroughly and above all, honestly, to honor God.
“Not with eyeservice, as menpleasers, but as the servants of Christ, doing the will of God from the heart, with good will doing service as to the Lord, and not to men.” Ephesians 6:6-7
When I toured hospitals in China in 1986, I was amazed that they only had one sheet of paper with a few characters on a clipboard hanging on the end of each patient’s bed. The patients were not allowed to sue their provider, so the documentation was very minimal. A Chinese friend told me each person keeps their own medical record in a notebook and takes it with them each time they go to the clinic for the doctor to write in. It sure seems like a much simpler system!