How to Chart in the Medical Field

From nursing assistants to neurosurgeons, medical charting is a requirement that serves many different purposes. Documentation serves as a description about the patient's condition and about medical care provided. It is important that providers document assessments, observations and statements made by the patient so proper care can be given and continued. There are many different formats you can use to help the provider create a complete, clear and concise report.

Instructions

S.O.A.P. Format

• 1

  Listen for subjective information from the patient. This information is what the patient states or how he describes his problem or complaint. For example, a patient states, "I am having chest pain and it started while I was sleeping." Subjective documentation is not supported by facts and can be open to interpretation.

• 2

  Look for objective information. This type of information is what the provider sees or what is observed. For example: "The patient's skin is very pale, cool and moist." Objective documentation supports a doctor's diagnosis and plan of care.

• 3

  Complete an assessment. An assessment is an evaluation of one or many areas of the body. Documentation can include a combination of subjective and objective information. Once the assessment is complete, providers need to document findings and statements from the patient. An example of this documentation would be, "Noted bruising in upper abdomen and patient grimaced when area was palpated."

• 4

  Plan the treatment or care to be provided. This area of documentation will vary depending on the medical provider's role. For example, a doctor will write about the ordered tests, ordered medications, treatment and continued follow-up care on later dates. Nurses may document on the plan of care for her shift. This may include walking and dressing changes. Documentation of care that was provided by paramedics will show care that was provided on the scene and in the back of the ambulance.

C.H.A.R.T. Format

• 5

  Write down the patient's chief complaint. Examples may include cough, chest pain, shortness of breath or sore throat. This is the reason for the visit.

• 6

  Obtain the patient's medical history. A medical history may include previous surgeries or hospitalizations from many years ago. Recent events are also part of a medical history. One example would be a patient's statement of having a fever with sore throat two days before an office visit. Good documentation of a patient's medical history provides a timeline for other providers and guidance for future decisions.

• 7

  Find out what the patient's allergies are. Be sure to document this clearly and often. It is important to know what medications or substances cause allergic reactions for the patient's safety.

• 8

  List what treatments the patient received and what their response was. Documenting the patient's response to therapies and medications is crucial to ensure the plan of care is working or not. This communication is also helpful in guiding a doctor's orders and follow-up care.

• 9

  Document if the patient was transferred to another department, facility or provider. It is important to document why the patient was transferred. It may be as simple as the patient being transferred from an Intensive Care Unit to a Medical/Surgical Unit because she has gotten better. In some cases, a patient is transferred to a different facility with specialized equipment and surgeons.