Documentation in Nursing
Why is documentation so important in nursing?
Importance of Documentation in Nursing:
- Ensures continuity of care
- Legal and ethical considerations
- Enhancing communication among the healthcare team
Common Challenges in Nursing Documentation:
- Time constraints: nurses need to time manage to give care to patients, and then have time to complete documentation
- Complexity of cases
- Infrequent yet critical documentation we do not do every day (and forget): (ie) blood administration, incident reports, falls, etc.
Do you know what needs to be documented in the case of a patient fall incident?
Case Studies: Real-World Examples
Case Study 1: Patient Fall Incident
Description of the Incident - Facts only:
How do you describe how you found the client?
Where was the client? In what position?
Did anyone see the client get into that position?
How did they get into that position if no one saw them get into that position?Did any part of the body get injured? If so, how?
Does the client need medical attention?
Circumstances leading to the fall:
What was the client doing just before the fall? (Walking? Sitting down? Reaching for something on the ground or floor?)
Was the area/floor near the patient wet? Was there a sign on the floor stating that it was wet?
Response and Care:
What was the immediate response?
What care was provided to the patient?
Example: “The client was assessed, and his right leg is longer than his left. The client is expressing a 9 on the pain scale of 0 to 10, with 10 being the worst ever and a nine being higher when he is moved or his leg is moved. The doctor was called, and an X-ray of the right hip was ordered. No other injuries were noted. The client was placed back into his bed and is awaiting an x-ray to come to his room for portable use.”
Documentation Steps:
Incident report details - facts only! No assumptions!
Patient assessment and follow-up notes
Outcome and lessons learned
Impact on patient care - the incident report will help prevent this type of fall for other patients.
Thorough incident documentation is important to help prevent this type of fall. Who was on the floor? Who was off for breaks? Who had the patient? Were all fall prevention interventions in place (ie. chairs, bed alarms, etc.)? Who was the last staff member to see the patient, and what were they doing then? All of this information should be included to help in the investigation and answer to how we prevent this in the future.
What needs to be documented in the case of an advanced directive?
Case Study 2: Advance Directive Documentation
Patient’s condition and decision making process:
Make sure the client has been educated on the process first, then they can express their wishes.
Allow client to share their personal values (ie. what they view as quality of life, religous or cultural views)
Interaction with family and healthcare team:
Educate the client’s family about the process, allow them to ask questions
Support the client’s wishes on who from their family and healthcare team can be involved in the process
Process of Documentation:
Record the advance directive done with the patient and their family exactly as it was stated
Communicate the patient’s wishes to the care team
Impact on Patient Outcome:
All medical and care decisions are influenced by the advance directive
Overall effect on patient care and family satisfaction are influenced by the advance directive
What is the best practice for documentation in nursing?
Types of Nursing Documentation and Best Practices:
1. Daily Documentation:
Patient Care Notes:
Include the abnormals such as pressure sore areas noted during a bath, it’s location, size, and how it appears.
Observations and assessments - any observations you make and assessments done (ie. fall assessment, interventions in place, and if they are working)
Vital signs and physical examinations
Best Practices:
Using objective, clear language.
Be sure to be clear and concise in your writing.
Document in real-time to avoid forgetting important details
Medication Administration Records (MAR):
Include date and time given
Include the drug name, does, time, route of administration, and who gave it
Patient response to medications (ie. BP, if patient’s response to drug was given to bring BP down)
Best Practices:
Double check orders for accuracy - always check orders in chart to ensure order in the MAR is correct
Record MAR immediately after administration - do not pre chart or wait until later to chart that it was given. Always record the amount given from the syringe if it was not the exact amount of the dose ordered. (Example: Ordered 1 mg, and full syringe is 2 mg/2 mls. How much fluid did you give? 1 ml)
Treatment Plans and Care Plans
Include daily goals and interventions
Include the problems documented on care plan (ie. if the client has a UIT what does the patient complain of today? Dysuria, dark colored urine, or a temperature? Is the patient drinking fluids?)
Progress notes
Best Practices:
Record regular updates to reflect patient progress
Update the care plan as needed for problems resolved, worsened, or remains the same.
Record collaborative input from the healthcare team. Document who is seeing the client (ie. the dietician if there is a wound involved, etc.)
What about documentation for things that happen infrequently? Documentation is still crucial!
2. Infrequent but Crucial Documentation
Incident reports:
Patient Fall Incident - See above
Include a description of the incident - Facts only! Where and how you found the patient, who you notified, etc.
Adhere to objective and factual recording
Circumstances leading to the fall
Immediate response and care provided to the patient. What injuries were found? Wwas ordered? How is the client tolerating treatment?
Patient assessment and follow-up notes. Follow up on incidents should just be facts - even if a medication error.
Best Practice:
Documentment who and what happened with facts - no more.
Always give the incident report to the nursing supervisor, do not put in the patients chart.
Advance Directives - See Above
Include the patient’s end-of-life wishes
Include legal documentation
Best Practices:
Ensure the directive is easily accessible
Communication with the healthcare team
Informed Consent
Doctor is the one who provides the information to the client
Include documentation of patient understanding and agreement. Nurses just document that the client understands and agrees with the information provided.
Situations requiring informed consent: Any situation where the procedure enters the body
Best Practices:
Clear explanation to the patient. Ask the client if he or she understands what the doctor told them. Review what they learned.
Ensure all questions are answered. If the patient still has questions, call the MD and inform of the need for more teaching.
Discharge Summaries
Include components of a thorough discharge summary. Discharge planning starts upon admission - start from the beginning and include what has happened since then.
Instructions for home care and follow-up appointments. Provide home instructions including medications, when they were taken last, and when they are due to be taken again.
Include any doctor appointments that the client has for follow up on this admission.
Best Practices:
Comprehensive and clear instructions - all instructions should include everything the client or family member needs to care for the client.
Include a phone number of who they can call if they have any questions or concerns
Confirm patient and caregiver(s) understanding
A few more notes…
Common Pitfalls and How to Avoid Them:
Omitting Critical Information:
Pitfall: Missing key details in documentation
Solution: Use checklists and templates for comprehensive assessments
Illegibility and Errors:
Pitfall: Illegible handwriting (for non-digital records).
Solution: Ensuring clear, legible entries. Print the information for easy reading, or type the information or directions. Double-check information recorded for accuracy
Incomplete Documentation:
Pitfall: Incomplete notes and records
Solutions:
Ensure completeness of documentation - Always make sure you have included everything you need by use of a checklist (See insight one for the check list).
Another way can be to have another nurse read your notes and see if she can think of what you are missing
Regularly update entries
The importance of thorough and accurate documentation cannot be overstated. Infrequent events that require documentation (incident reports, advanced directives, informed consents, etc) are still just as crucial as daily documentation (patient progress reports, MARS, etc.). As nurses we are life-time learners, and we should continue to review and attend trainings held for reviewing proper documentation. Proper documentation in crucial for proper patient care and positive patient treatment outcomes.
Additional Resources:
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