The Critical Role of Charting in Nursing

The Critical Role of Charting in Nursing

Nurses have many responsibilities, but charting is perhaps the most important to the patient and themselves. Below, we’ll explain the critical role of charting in nursing and how it can help prevent medical malpractice lawsuits, treatment mistakes, and more.

Initial Assessment

Charting is integral to a patient’s health and well-being as soon as they arrive at a hospital or medical facility. One of the first things that happens is a nurse takes down a patient’s basic health facts on the chart, like their height, weight, blood pressure, etc.

The nurse will also ask questions to the patient or their family or friends about their medical history. This information is helpful to understand future treatment considerations, gauge their immediate condition, and note any treatment red flags like allergies to medication. This initial assessment is critical to the success of the treatment, so if the information is incomplete or inaccurate, it could have devastating effects on the patient.

Continuity of Care

Charting in nursing plays a critical role in the continuity of care for a patient. There are many moving parts and components during a treatment plan for patients, so monitoring what’s happened and what still needs to happen can be challenging.

That’s why the chart documents who did what, when they did it, and the treatment results. Without proper documentation of treatment actions, making simple but harmful mistakes—like administering the same medicine to a patient twice—becomes more common.

Treatment Evaluation

Charting is also integral to evaluating the patient throughout the treatment plan. Nurses must keep a chart up to date regarding a patient’s status and how the treatment affects them so everyone on the team can understand the progress. Charting keeps the entire treatment team on the same page regarding the patient’s condition and provides the most up-to-date information if changes to the treatment are necessary.

Malpractice Prevention

Charting is also incredibly important for nurses to protect themselves and avoid medical malpractice lawsuits. Charting is one of the c’s of medical malpractice prevention, along with compassion, competence, and communication, and is often considered the most important component.

Charting provides written documentation of the patient’s medical history that helps everyone stay on the same page and avoid mistakes while providing a written timeline of the patient’s condition. If there is a malpractice suit, the chart is one of the key pieces of evidence, so nurses must always chart correctly and accurately for their benefit.