Your charting should tell a clear story about the patient’s condition and care every shift. But let’s be honest, it’s easy to fall behind on documentation when you’re busy focusing on patient care. There’s nothing worse than rushing at the end of your shift to catch up just so you don’t have to stay late.
Having a regular charting routine can really help you stay organized and on top of your documentation. This is especially useful for travelers, allowing you to quickly get used to new charting systems and what each facility expects.
Start of Shift: Initial Assessments
Your initial patient assessment establishes the baseline for your shift and is one of the most important things to chart for every patient during each shift.
Review active orders for each patient.
Review lab results and notify providers of abnormal results.
Complete and document your initial head‑to‑toe assessment within the first hour of your shift for all assigned patients.
Document baseline vital signs and make sure they align with orders and parameters for when to notify providers.
Review, assess, and chart each patient’s current pain level and pain interventions in place.
Check and document IV sites, dressings, drains, and lines, including their condition, patency, and any issues requiring follow‑up.
Verify and chart patient ID bands and allergy alerts to ensure a clear record of completed safety checks.
Note any changes from the prior shift report and update fall risk assessments or other risk tools as indicated.
Hourly & Ongoing Documentation
Once your baseline charting is in, the focus shifts to documenting all assessments, interventions, and patient responses as they happen.
Vital signs: Chart vital signs according to facility protocol or ordered frequency, including any rechecks for out‑of‑range values or patient complaints.
I&O: Record intake and output when required, especially for patients on strict I&O, diuretics, or with fluid balance issues.
Medication administration: Document every medication administration with correct time, route, and patient response.
Assessments: Document required reassessments (e.g. pain, neuro) as required by policy/orders.
Interventions: Document any care provided such as repositioning, wound care, suctioning, etc.
Changes in condition: Chart patient complaints or new symptoms (e.g., chest pain, dyspnea, confusion) along with your assessments and actions.
Provider communication: Document all provider notifications with their response and any orders received.
Education: Document patient or family education provided, plus evidence of understanding or refusal.
End of Shift Charting
Complete all required charting, then review all documentation for accuracy and completeness.
Write a concise shift summary or end-of-shift note that focuses on major changes, interventions, and current status.
Document any pending orders or follow-up needed.
Prepare a structured handoff report using SBAR format.
Documenting Guidelines & Tips
Document in a timely manner. Although it’s not always possible to document immediately after you provide care, you should try to document as soon as possible. It’s easier to document accurately when things are fresh in your mind, and you’re less likely to forget important details.
Be objective & stick to the facts
Chart observable data, measurements, and patient behaviors. Avoid charting a subjective description, such as “Patient is acting crazy and angry.” Instead, describe the specific actions or behaviors you observed (e.g., Patient is shouting, using profanity, and pacing the room; refuses to sit for assessment).
Your documentation should be as clear and specific as possible.
For example, don’t use vague terms like “small” to describe a pressure injury. Instead, document something like, “2 cm x 3 cm unstageable pressure injury noted to sacrum. Eschar noted to wound bed.”
Always document the patient’s response to your interventions (e.g., “Pain decreased from 8/10 to 3/10 one hour after Morphine administration”).
Note all communications. Document calls to providers, including time, exact message, and the provider’s response.
For example, “Notified Dr. Smith at 10:15 regarding elevated BP (180/95). Provider placed an order for 10 mg IV Hydralazine.”
Follow facility standards and specific charting requirements.
Don’t use shorthand or abbreviations that aren’t widely accepted.
The public may contact The Joint Commission’s Office of Quality Monitoring to report concerns about the quality and safety of patient care provided by a Care Team Solutions employee. Rest assured, you can report a patient safety event or concern about a healthcare organization to The Joint Commission without fear of retaliation. To report concerns or register complaints about a Joint Commission-certified organization, click here to learn more, call 1-800-994-6610 or e-mail complaint@jointcommission.org.
