It’s almost the end of the shift and Nurse Leo is making sure he’s got everything covered. He checks his to-do list and smiles as he notes that he has accomplished everything that needs to be done. However, there’s something bothering him – he’s not that confident with his documentation. He feels that something is lacking. That somehow, there’s still something that needs to be done in order for it to be better, he just can’t pinpoint what it is.
Bothered and unsettled, he leans back on his chair while he ponders on what is lacking and how he can improve his documentation. ‘How, how, how?’ He keeps on asking himself. ‘How will I be able to improve my documentation?
Professional nurses hold the responsibility of ensuring safe, quality patient care and the only proof of this is through nursing documentation.According to Kelley, Brandon, & Docherty (2011), documentation of patient care is a fundamental, yet critical, skill used by nurses to communicate the current health status of the patient’s individual needs and responses to care.
Tips on how to improve your nursing documentation
- Document your assessment findings as soon as possible after you conduct the health history andphysical assessment.
- Be aware of critical times such as:
- abnormal vital signs
- change of nursing shift or patient hand offs
- taking verbal orders
- noting physician’s orders
- verifying medication orders
- If using an assessment form or computer template to answer every question, do not leave anyblanks. If it does not apply to the patient, indicate that with “not applicable.”
- Remember, you accept accountability for your assessment when you sign your name.
- Use direct quotes from the patient or family so that you capture the intent.
- Clarify any information that seems incomplete (Sparks, 2014).
- Describe everything exactly as found by inspection, palpation, percussion, or auscultation.
- Do not use general terms such as “normal,” “abnormal,” “good,” or “poor”.
- If you use Within Normal Limits (WNL), be sure that there is a description of what that means builtwithin the tool. It could be a drop-down in the EMR that defines what WNL is for each body system.
- Your policy on assessment must include a minimum time frame for assessment completionand documentation. But do not box yourself in with a very tight time frame, as you will beheld to whatever the policy states regardless of staff practice.
- Nurses need to first ask patients to describe two or three goals they would like to achieve. The nursethen needs to consider:
- Patient’s state of health and overall prognosis
- Expected length of stay
- Patient values and cultural considerations
- Other planned therapies for the patient
- Available resources (human, material, financial)
- Current scientific evidence
- Any changes in patient status that changes your expected outcome (Taylor, et al., 2014)
- Regardless of the charting method used, nursing documentation must be:
- Free of grammatical/spelling errors
- Free of errors/erasures
- Completed in blue or black ink
- Late entries and any corrections entered should be per policy and procedure.
- Allergies should be highlighted and flow sheets filled out completely.
- No charting should be done in advance.
- Charting patterns including flow sheets will be reviewed.
- Consult the nursing policy and procedure for accepted abbreviations.