One of the things that are most daunting to learn as a nursing student or new nurse is how to understand all the material in a patient’s chart. The patient’s chart contains so much material and figuring out what is important for you to do your job as a nurse can be confusing.
I recently had a reader submit this question and I thought it was terrific. I remember being a nursing student, and I was so overwhelmed by learning the patient’s chart. I thought to myself, “How am I ever going to learn this material?”
In this article, I want to give you some easy ways on how I mastered a patient’s chart. Hopefully, you will be able to take these tips with you so you can better understand a patient’s chart.
What this article will cover:
- Importance of a good report sheet template
- Ways to Master it?
- What’s the important information in a chart?
Video on How to Master a Patient’s Chart
I’ve made a video where I talk about how to do this on YouTube. Don’t forget to subscribe to my YouTube channel for more videos!
Get a Nursing Report Sheet Template
A patient’s chart contains so much material and it can be overwhelming, especially for nursing students and new nurses to comprehend it all. In addition, it is impossible to memorize everything about all of your patients, especially if you have multiple patients.
What is a nursing report sheet template? This is a sheet of paper you use to write down important information you receive in nursing shift report.
I highly recommend you develop or use a nursing report sheet template to keep all of the important information about your patient organized. Report sheets templates are so great because during report you can write down information about your patient (decreasing the time you have to spend in the chart looking for this information).
In addition, a report sheet is excellent for quick reference when a doctor has a question, helps you keep your day organized, and allows you to add notes for important things you need to remember.
I’ve developed some FREE nursing report templates you can use to help you with this.
Easy Tips on How to Master a Patient’s Chart
Ask questions in report! When you are getting report on your patient you need to know the important information to ask so you won’t have to spend valuable time during your shift looking up patient information. If you are not comfortable with nursing report, I highly recommend you watch this nursing video.
Take Advantage of Clinical & Orientation Time! This is the best time where you can sit down (find a quiet place) and dissect the patient’s chart. While you are doing this make sure you understand what is found in every tab (for online charting) or divider (if your still paper charting).
Figure out what’s vital! As a new nurse or nursing student, you need to know which sections of the chart are helpful to you. Below I have broken down the sections that “Helps you learn your patient” and “Helps you do your nursing tasks”.
Take a charting course! Many places of employment will offer or require new nurses to take an introductory charting course. In this course you will learn how to access patient information and where everything is located. I took a course similar to this and it was very helpful. I highly recommend you take a course like this if it is offered.
What’s the Important Information in a Patient’s Chart?
Of course everything is important, but there are certain areas that you will use all the time. I wanted to break the important sections down in the easiest way to understand. So, I’ve broke them down in two sections: “Helps you learn your patient” & “Helps you do your nursing tasks”.
Helps you Learn Your Patient:
- History & Physical (H&P): This is completed by the doctor (and every doctor consulted for the patient’s care) and is so resourceful because it tells you:
- Patient’s current problem, health history, surgical history, allergies, medications, and what the doctor’s treatment plan is.
- Lab Work: You will constantly be looking at recent and previous lab work. This section allows you to see how your patient is progressing. For example, say your patient is ordered a morning dose of IV Lasix 60mg and you noticed that their morning Potassium level came back as 2.0. You would probably want to call the doctor and see if they want you to give the morning dose of Lasix since the Potassium level is so low. (note: Lasix is a diuretic that wastes potassium).
- Diagnostic Testing Results: This shows you the result of tests you patient has had and this is very important so you can keep you patient updated on their test results. You can see results of chest xrays- stress test, ekgs, echocardiograms etc.
Helps you do your Nursing Tasks:
Vital Signs & Flow Sheets: These areas will be used to chart vital signs, intake & output, weighs, and keep track of flow sheets for IV changes, central line dressing changes, care plans etc. This is a great place to see what is normal for your patient and what tasks you need to complete during your shift.
Nursing Notes: Gives you a snap shot of what has been going on with the patient throughout the other shifts.
Doctor’s Orders: SUPER IMPORTANT. I always check this section frequently for any new orders and future orders. Here you can see ordered lab work, future testing, new medications ordered etc.
Get familiar with a chart by taking the time to sit down with one and dissect it and invest in a good report sheet template.
You may be interested in: Questions to Ask During Nursing Shift Report