The Reality of Nursing Charting
Time spent, what to chart, what not to, legal protection.
Charting is 25-40% of nursing time. The reality differs from school.
What to chart
Objective findings. Interventions. Patient response. Provider communication.
What NOT to chart
Opinions ('patient is rude'). Speculation. Hearsay. Anything inflammatory.
Legal protection
Chart contemporaneously when possible. Don't chart in advance. Use late entry process if delayed.
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