Charting Guidelines for the HUC

Purpose of Charting

Clear, accurate and accessible documentation is essential to safe, quality care in hospitals. Charting in the hospital refers to documentation that includes medical and clinical data. Many health care professionals, including physicians and allied health care professionals such as physiotherapists, social workers, dietitians, or nurses, may be involved in creating and managing medical records (Ighani, 2024). Effective charting serves many purposes:

• It provides a permanent record of the patient’s information.
• It tracks the progress of the patient’s condition throughout the hospitalization from admission to discharge. It serves as an information sheet of the medications and procedures rendered to the patient.
• It provides legal evidence for cross-examination in the event of a complaint or lawsuit.
• It serves as evidence of continuity of care.
• It serves as research material for retrospective studies (Hope, 2023).

Types of Charting Used in the Hospital

The type of charting used depends upon the type of caregiver, the information being charted, the type of clinical information system used, and the hospital’s specific guidelines. Some of the most common charting methods include:

• Charting by exception (CBE): Instead of comprehensive note-taking, CBE focuses on documenting only significant deviations from the norm. It assumes that everything is normal unless noted otherwise. This approach streamlines charting by using checklists and flow sheets to document patient information, allowing nurses to to simply check some boxes; however, the down side is that information may be missed (Correll, 2023).
• SOAP notes: SOAP charting is an acronym for subjective, objective, assessment, and plan. It is a method of organizing medical notes into a structured format that provides a clear and concise picture of a patient’s health status and treatment plan. Each component is broken down as follows:
  • Subjective (S): This section captures the patient’s subjective experiences and feelings.
  • Objective (O):  This section includes observable and measurable data, for example, vital signs.
  • Assessment (A): This section includes assessment data summarizing the salient points based on the information collected in the subjective and objective sections.
  • Plan (P): Outlines the plan of care including interventions, medications, and follow-up steps (TrackStat, 2020).
• Narrative notes: These are like a running log of everything that happened with the patient during a particular shift. Events are recording in a chronological order, and should be concise and objective in description (Correll, 2023). This method is the one the HUC would typically use when documenting an occurrence.

Guidelines for HUC Charting

The HUC does not provide direct patient care in a hospital; however, they may occasionally be required to document in the patient record, including:

• notations indicating what steps they have taken with a physician order if not CPOE,
• stat verbal reports from care areas/providers inside or outside of the hospital (should be introduced by what report type and provider, then written word-for-word using parentheses to denote the information provided), and
• documenting a situation that occurred where they were the witness, such as witnessing a patient fall or a patient leaving the hospital against medical advice (narrative charting).

In all cases of documenting on paper-based records, the HUC should follow all of these best practices:

• ensure that it is the correct patient record,
• use a black pen,
• write clearly,
• include the date and time of entry, and
• sign any entry with their First Name, Last Name, and designation.

Error Correction

Occasionally, a health care provider will need to correct an error in their documentation caused by:

• documenting on the incorrect patient record
• documenting incorrect information

It is important for the HUC to remember that only the person who made the error may correct it. Error correction methods will differ depending on the type of documentation. Error correction in the e-Chart is usually quite simple and just requires editing existing documentation. However, correcting documentation in the p-Chart requires the following:

• stroking through the incorrect information in black pen once (it is essential to leave the information viewable, the HUC should never use whiteout/correction tape or scratch through documentation),
• writing “error” immediately adjacent to the incorrect documentation,
• adding the correct documentation beside the incorrect documentation, and
• signing and dating the correction.

References

Correll, R. (2023, December 21). Nurse charting 101: Your guide to patient documentation. Berxi.

Hope, I. (2023, June 29). Charting for nurses. RN Speak.

Ighani, L. (2024, January 15). Ultimate guide to nurse charting, documentation, and notes. Nursa.

TrackStat. (2020). An Introduction to SOAP charting: Streamlining medical documentation and improving healthcare records.

Attributions

“Woman in dark scrubs at table writing,” © Conestoga College, licensed Creative Commons – Attribution-NonCommercial-ShareAlike 4.0 International.