Nursing Documentation

Nursing documentation should reflect the nursing process; once the intervention based on assessment is done the follow up should occur, just like evaluation in the nursing process. Correct nursing notes reflects your nursing action. While each step of your nursing action is guided by the nursing process, nursing documentation should also reflect it. We can call it the second principle of the nursing charting; if not sure what to include in the notes just remember describe your assessment, identified problem and based on it your intervention (action), and your follow up (evaluation. You can access introduction to nursing documentation page here.

The rules are simple but how would it looks in the clinical practice? Let’s take a look at your shift. At the beginning what should be done? Visiting each patient, introducing self, explaining the plan of care for the shift and asking for feedback, is that correct? Your nursing documentation may look like: Date, time, “Introduced myself to pt, POC discussed, pt v/u.” This simple statement describes your action. It is important to check with the facility policy what abbreviation can be used. Pt=patient, POC=Plan of Care, v/u=verbalized understanding. This introduction will be acceptable if supported by the additional nursing notes with the patient condition.

Most facilities use the flow sheet for the shift assessment. If the flow sheet consists of data regarding the patient mental and physical state these should be included in this form; otherwise it must be included in the nursing notes. It is not a good practice documenting the teaching while the mental status is unknown; if the patient has a history of confusion, or is prone to delirium due to the risk factors your teaching regarding the treatment may be questioned. The fact that one part of the nursing notes is questioned it may affect the veracity of the entire nursing charting. This may affect entire chart reflecting nursing intervention for the patient if the occurred problem is investigated. In other words if the improper charting is found in one part of the notes, entire charting may be questioned.

It is very important to remember: the action and performance during the shift reflect how good nurse someone is, but only nursing notes reflects what was done. Routinely your nursing documentation may briefly be reviewed by the charge nurse or left unattended. The notes may be reviewed very careful if there is a case open; sometimes several weeks after the fact occurrence. Most likely nobody nor you will remember what exactly happens, and the only proof of your intervention in response to the problem will be your charting.

Let’s back to your shift. Introduced yourself and identified your patient, POC explained, your A/Ox3 patient v/u (alert and oriented times 3 to self, time and place), and nursing assessment completed. So far so good, let’s consider at this time there are no problems; is that all? It may not. The good way of documenting is following the patient’s care plan. Each care plan is build with the list of the potential problems. Some problems may be addressed once per shift while others more often; however, there are potential problems which always need to be included in the nursing notes, and explained how they were addressed and resolved.

The knowledge deficit, pain, safety or skin integrity may be the example. Why these and why not the respiratory status, or cardiovascular system? The list of potential problems includes areas of common concern which usually pertain to every patient. However, once resolved does not need to be frequently addressed again. Let’s review the knowledge deficit problem. While the newly admitted patient would have a lot of questions regarding his status, follow up treatment, medication administration, diagnostic tests and so on, once all details explained s/he will only need the explanation of the POC for the day. The same with the pain; if the patient is admitted to the hospital with no pain related diagnosis, or skin integrity when the patient is not prone to skin problems. Each of these problems should be included in the chart at least once per shift. However, when there is no patient complains in these areas during the shift there is no need to include them in the notes again.

Here, is how your initial nursing note may look: Date, time, “Introduced self to pt, pt A/Ox3, POC discussed pt v/u. No c/o pain, skin dry and intact, pt resting in bed, no distress noted or verbalized, pt safety maintained” (c/o=complains of). It is clear that the safety, skin and pain potential problems were included and resolved at this time. General assessment findings and the fact that there is no patient complains at this time were briefly summarized in the statement: “no distress noted or verbalized.” The nursing notes can be limited to the short statement only if detailed assessment is documented in the flow sheet and the problems list completed. The general findings are included in nursing notes; all relevant facts and details are entered into the flow sheet and the problems list. There is no need to include the same details in the flow sheet and the nursing notes. For example if the flow sheet has the positions: call bell in reach, bed in low-position side rails up x3, and on each position the check mark was placed there is sufficient to include only short note “safety maintained.” Entering detail in the notes while they are in the flow sheet are nothing else than double charting; this is the time wasting.

Your documentation should reflect all areas of concerns, as well as all relevant identified problems, interventions and follow ups. We will discuss the documentation problems later. At this time let’s assume the patient is in stable condition. Is that all what should be included in the notes? I mentioned previously what must be documented regarding your patient’s vital systems state and current status. How it can be done? While there is nothing new and no changes to the patient status (based on your actual assessment), it is usually sufficient to include only short note. It may look like: “no changes in the pt status.” Check with your facility policy what are the requirement regarding how often the patient condition should be rechecked. Consider what documentation is due; if there are no strict rules regarding documentations the recommendation would be to perform the brief check for your stable client at least every four hours. Brief note in the chart should be included.

Remember: service not documented is considered not done.

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