March, 1978 – 11:30 p.m.
After finishing walking rounds with the night shift nurse, I clocked out and sat down beside the chart rack to write notes on each of my five assigned patients before I went home. I usually completed some of my charts during my shift, but with the nonstop evening, I barely gulped down my dinner. The hospital administration did not pay us overtime to complete our charting. I began my mandated notes in the S-O-A-P format.
S is for subjective- what the patient says.
O is for objective – what you observe.
A is for assessment.
P is for plan.
I took the heavy three-inch thick chart and turned to the tab marked “Nurses Notes”. I took out my blue ink 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 precise words of 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 a below-the-knee amputation two days previously. I scanned her problem list and chose Pain and Diabetes from her list. I wrote with 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.
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 invented the copy machine, we switched to black ink so the charts were more legible when copied.
Several years later when I worked in labor and delivery, we wrote our initials and time on the fetal monitor strip whenever we entered the mother’s room, gave any medication, or did a procedure. As a visiting nurse in the 1990’s, I used a checklist system and left a carbon copy in the patient’s home for the next nurse. When I worked in a nursing home as a nurse practitioner, the dictation service with secretaries worked well. And we returned once again to the S-O-A-P format.
In my Federal job, electronic patient records made the paper charts obsolete. My machine dictation resulted in 70% accuracy requiring significant time to correct all the mistakes. But at least everyone’s notes were legible and we no longer wasted time hunting for lost charts. However, on occasion, the computer system crashed and we had no access to the patient records and had to close the clinic.
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, my handwriting has also deteriorated. Charting wasn’t the most satisfying part of my nursing career, but necessary for communication and a required part of my job, so I 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
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 minimal. A Chinese friend told me each person keeps their own medical record in a notebook and takes it with them when they visit the clinic for the doctor to write in. It sure seems like a much simpler system.