New Nurses: How to Chart

Writing a nurses's note is a skill that you will be doing several times a day, each day that you work.

It is an essential part of providing care and also most important when it comes to protecting your nursing license. A nurse's note can be a key witness in a personal injury/negligence lawsuit. 

Below you will kind key steps to perfecting this basic skill.

Before you begin:

Make sure you have the RIGHT CHART.-Many new nurses including myself have written about the wrong patient in the wrong chart.
Write in black ink- Colored inks are harder to copy and look unprofessional
Have your assessment done.-Do not try to chart on a patient you have not assessed, you will not have much pertinent information to document.
Know that you will be writing more than one note- Keep the information short and to the point. Nurses sometimes need to write several notes during their shifts.