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.
I wearily began writing using the S-O-A-P format in the heavy three-inch thick chart under the tab marked “Nurses Notes” with my blue ink pen. Day shift charted in black ink, evening shift used blue ink, and night shift used red ink.
S is for subjective- what the patient says.
O is for objective – what you observe.
A is for assessment.
P is for plan.
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 using only approved abbreviations. 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, walked out to the parking lot, climbed in my car, and drove home through the black night.
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 notes were more legible when copies were made.
When I worked in labor and delivery, I had to write my initials and time on the fetal monitor strip whenever I entered the mother’s room, and whenever I gave any medication or did a procedure. Only once was I called to go to the office of the hospital attorney to review my charting I did on a mother who we sent home in false labor. She later came back that night but delivered the baby in the hospital parking lot before she made it to the labor and delivery unit. She was now suing the hospital for sending her home, and I was the nurse who did the last assessment. I reviewed my charting about a year after the incident and my instructor’s words came back to my memory. Thankfully, my charting was complete and I never heard the outcome of the lawsuit. They likely settled out of court.
When I was a visiting nurse in the 1990’s, we used a checklist 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. We used both paper charts and electronic medical records which was confusing at times.
In my final job with the federal government, we only had an electronic patient record. The days of heavy paper charts in racks had ceased. I had machine dictation which was only about 70% accurate, so it took quite awhile to correct all the mistakes. But at least we could read everyone’s notes and never had to go hunting for lost charts. However, when the computer system crashed, it shut down the whole system because we had no access to the patient records. Thankfully, that didn’t happen often. I felt sorry for the providers who had never taken a typing class and had to spend long hours at home in the evening completing their patient’s charts for the day with the old hunt and peck method of typing.
When I 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 every job, so I always tried 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 (KJV)
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!