Nursing Documentation

Nursing Documentation

Nursing documentation

  • Introduction

Aim

Definition of Terms

Process

Special Considerations

Companion Documents

Evidence Table

References

Introduction

Nursing documentation is essential for good clinical communication. Appropriate legible documentation provides an accurate reflection of nursing assessments, changes in conditions, care provided and pertinent patient information to support the multidisciplinary team to deliver great care. Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice.

Aim

To provide a structured and standardised approach to nursing documentation for inpatients. This will ensure consistency across the RCH and improve clinical communication.

Definition of Terms

Documentation: encompasses all written and/or electronic entries reflecting all aspects of patient care communicated, planned recommended or given to that patient.
‘End of shift’ progress notes: nursing documentation written as a summary at the end or towards the end of shift.
‘Real time’ progress notes: nursing documentation written in a timely manner during the shift.
ISBAR: (Identify, Situation, Background, Assessment, Recommendation) framework for clinical communication
Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
Shift assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift.

Process

Nursing documentation will support the process;

  1. Patient assessment,
  2. Plan of care
  3. Real time progress notes

Patient assessment

An admission assessment is completed and documented on the Nursing Admission (MR850/A) as perNursing assessment guideline.
Exceptions: SeeSpecial Considerations
At the commencement of each shift, following handover, patient introductions and safety checks, a ‘commencement of shift assessment’ is completed as outlined in theNursing assessment guideline. These assessments are documented on the Patient Care Plan (MR 856/A). If there is more information gained from this assessment than space allowed, additional information is documented in the progress notes. In Neonates (Butterfly) and PICU (Rosella), commencement of shift assessments are completed in progress notes.

Plan of Care

Taking into consideration the patient assessment, clinical handover, previous patient documentation and verbal communication with the patient and family the plan of care for the shift is made and documented on the Patient Care Plan (MR 856/A). The plan should be negotiated with patients’ and their carers to ensure clear expectations of care, procedures, investigations and discharge, are set early in the shift. The plan of care should align with information on the patient journey board.

Real time Progress Notes

Documentation is captured in the patient’s progress notes in ‘real time’ throughout the shift instead of a single entry at the end of shift.
Any relevant clinical information is entered in a timely manner such as;

  • Abnormal assessment, eg. Uncontrolled pain, tachycardic, increased WOB, poor perfusion, hypotensive, febrile etc.
  • Change in condition, eg. Patient deterioration, improvements, neurological status, desaturation, etc.
  • Adverse findings or events, eg. IV painful, inflamed or leaking requiring removal, vomiting, rash, incontinence, fall, pressure injury; wound infection, drain losses, electrolyte imbalance, +/-fluid balance etc.
  • Change in plan (Any alterations or omissions from plan of care on patient care plan) eg. Rest in bed, increase fluids, fasting, any clinical investigations (bloods, xray), mobilisation status, medication changes, infusions etc.
  • Patient outcomes after interventions eg. Dressing changes, pain management, mobilisation, hygiene, overall improvements, responses to care etc.
  • Family centred care eg. Parent level of understanding, education outcomes, participation in care, child-family interactions, welfare issues, visiting arrangements etc.
  • Social issues eg. Accommodation, travel, financial, legal etc.

Progress note entries should include nursing content and evidence of critical thinking. That is, they should not simply list tasks or events but provide information about what occurred, consider why and include details of the impact and outcome for the particular patient and family involved.

All entries should beaccurate and relevantto the individual patient. Generic information such as ‘ongoing’ is not useful.
Duplicationshould be avoided. Blanket statements about information recorded on other medical records are not useful, for example, ‘medications given as per Medication Administration Record (MAR).
Professional nursing languageis used for all entries to clearly communicate assessment, plan and care provided. For example; ‘TLC’ does not reflect nursing care.
Abbreviationsshould be consistent with RCH standards.

Structure

The structure of each progress note entry should follow theISBARphilosophy with a focus on the four points of Assessment, Action, Response and Recommendation.
Identify.Positive patient identification and ensure details are correct on documents. Write the current date, time and “Nursing” heading. The first entry you make each shift must include your full signature, printed name and designation. Subsequent entries on the same shift must be identified with date/time and ‘Nursing’ but may be signed only.
Situation & Background.not often required for ‘real-time’ entries. Maybe relevant for admission notes or transfer from one dept to another.
Assessment.What does the patient look like? What has happened?
Action.What have you done about it? Interventions, investigations, change in care or treatment required?
Response.How has the patient responded? What has changed? Improvement or deterioration?
Recommendation. What is your recommendation or plan for further interventions or care?
Examples of real time progress note entries
2/7/2014
09:40 NURSING. Billie is describing increasing pain in left leg. Pain score increased. Paracetamol given, massaged area with some effect. Education given to Mum at the bedside on providing regular massage in conjunction with regular analgesia. Continue pain score with observations.
10:15 NURSING. Episode of urinary incontinence. Billie quite embarrassed. Urine bottle placed at bedside.
14:30 NURSING. Routine bloods for IV therapy taken, lab called- low Na+. Medical staff notified, maintenance fluids reduced to 5ml/hr. Repeat bloods in 6/24. Encourage oral fluids and diet, if tolerated, IV can be removed.

Special Considerations

Critical care areas (Rosella & Butterfly).
In these clinical areas, the ‘commencement of shift’ patient assessment and plan of care should be documented in the progress notes. Real-time progress notes are captured in either the clinical comments section of the observation charts or the in progress notes.
Nursing Admissions are completed:

  • Neonates (Butterfly) – Neonatal Unit Nursing Admission/History, (MR 851/A)
  • Paediatric Intensive Care (Rosella) –PICU Management Plan, (MR 855/A)

Emergency.
The Emergency Department have department specific documentation tools, however progress notes should follow the structure as detailed above.
Theatres.
The Operating Suite uses ORMIS (Operating Room Management Information System) to record all surgical procedures

Banksia.
The patient population in this unit requires assessment that is continuous throughout the shift and so commencement of shift assessment and plan of care are incorporated into progress notes.
Nursing Admission - Day stay.
May be used for patients staying less than 24hours in the areas of Day Medical Unit or Day of Surgery.
Wallaby Ward.
Commencement of shift assessments are completed verbally within two hours of the shift commencing by contacting families.

  • “How is your child?”
  • “Is there any change with your child since yesterday?”

Verbal commencement of shift assessments along with ABCDF, risk, OH &S and medication assessments are documented on the Patient care plan (MR 856/A).
All plans for care are documented on the Patient care plan and real-time progress notes should follow the structure as detailed above.
Less than 24hr Admissions (Oximeters + Ambulatory Blood Pressure Monitoring)
Commencement of shift assessment and real-time progress notes are documented.
Note: do not require Nursing Admission Forms.
CVC Care
Commencement of shift assessment, Patient care plan and real-time progress notes are documented.
Note: do not require Nursing Admission Forms.

Companion Documents

  • Documentation procedure
  • Patient Identification
  • Nursing assessment
  • Legislative compliance

Evidence Table

Complete evidence table document available at

References

  • Björvell, C., Thorell-Ekstrand, I., &Wredling, R. (2000). Development of an audit instrument for nursing care plans in the patient record. Quality In Health Care, 9(1), 6-13.
  • Blair, W., & Smith, B. (2012). Nursing documentation: Frameworks and barriers. Contemporary Nurse, 41(2), 160-168
  • Cheevakasemsook, A., Chapman, Y., Francis, K., & Davies, C. (2006). The study of nursing documentation complexities. International Journal of Nursing Practice, 12, 366-374.
  • Collins, S. A., Cato, K., Albers, D., Scott, K., Stetson, P. D., Bakken, S., &Vawdrey, D. K. (2013). Relationship between nursing documentation and patients’ mortality. American Journal of Critical Care, 22(4), 306-313.
  • De Marinis, M. G., Piredda, M., Pascarella, M. C., Vincenzi, B., Spiga, F., Tartaglini, D., Alvaro, R., &Matarese, M. (2010). ‘If it is not recorded, it has not been done!’? consistency between nursing records and observed nursing care in an Italian hospital. Journal of Clinical Nursing, 19, 1544-1552.
  • Jefferies, D., Johnson, M., & Griffiths, R. (2010). A meta‐study of the essentials of quality nursing documentation. International journal of nursing practice, 16(2), 112-124.
  • Johnson, M., Jefferies, D., & Langdon, R. (2010). The Nursing and Midwifery Content Audit Tool (NMCAT): a short nursing documentation audit tool. Journal of nursing management, 18(7), 832-845.
  • Kargul, G. J., Wright, S. M., Knight, A. M., McNichol, M. T., &Riggio, J. M. (2013). The hybrid progress note: Semiautomating daily progress notes to achieve high-quality documentation and improve provider efficiency. American Journal of Medical Quality, 28(1), 25-32.
  • Newell, R., &Burnard, P. (2006). Vital notes for nurses: research for evidence-based practice. Oxford; Malden, MA Blackwell.

Document Control

Complete document control document available at

Please remember to read thedisclaimer.

The development of this clinical guideline was coordinated by Sophie Linton, CNC, Nursing Innovations and Kylie Moon, CNC, Nursing Innovations. Approved by the Clinical Effectiveness Committee. Authorised by Bernadette Twomey, Executive Director Nursing Services. Guideline first published November 2014.

17 Tips to Improve Your Nursing Documentation

ByKatie Moraleson Thu, Oct 25, 2012

styleDocumentation in nursing is a key factor in our role and responsibility as a patient care advocates. It is critical for determining if the standard of care was rendered to a patient to defend prior nursing actions. Failure to chart, omissions, and poor communication are hard to defend.

Whether you are a seasoned nurse or anew grad, here are 17tips worth reviewing:

A better option is “MD paged, assessment findings discussed, and no additional orders at this time.”

  1. Be extra careful when you think you are "too busy."It is ironic that it is at your busiest hour(s) that the importance of documenting is the most crucial. Be aware of critical times such as:
  2. abnormal vital signs
  3. codes
  4. transfers
  5. change ofnursing shiftor patient hand offs
  6. taking verbal orders
  7. noting physician’s orders
  8. verifying medication orders
  9. Remember thatcritical values should be reported to a nursewithin 15 minutesof lab verification.
  10. The nurse must report critical values to the physician within 30 minutes. If the physician can’t be reached, follow the facility’s fail safe plan.
  11. Avoid general statements.Beware of general statements that can be misconstrued. For example, you wrote “Dr. Smith called.” Did you mean:
  12. you called and are waiting for a return phone call?
  13. the physician called the nurse?
  14. the nurse called and spoke to physician?

A better option is “MD paged, assessment findings discussed, and no additional orders at this time.”

  1. Some facilities use nursing charts by exception.They indicatefindings are “within defined limits” (WDL) unless otherwise noted.Know these defined limits.Charting by exception requires selecting “abnormal” and writing applicable text.In such cases, text will be carefully scrutinized.
  2. Regardless of the charting method used,nursing documentation must be:
  3. Objective
  4. Legible
  5. Free of grammatical/spelling errors
  6. Free of errors/erasures
  7. Completed in blue or black ink
  8. Accurate
  9. Late entries and any correctionsentered should be per policy and procedure.
  10. Allergies should be highlightedand flow sheets filled out completely.
  11. No chartingshould be done in advance.
  12. Charting patterns including flow sheets will be reviewed.“Too perfect” charting may raise doubts. Patient assessment such as fall risk or skin assessments must be carefully performed and documented. Failing to do so is a common error.
  13. Documentation should include staff notified and steps taken.Careful nursing assessment makes spotting changes in the patient’s condition easier. One recommendation is the DARE approach: document Data, Action, Response, and Evaluation. The RN is responsible for analyzing data.
  14. Consult the nursing policy and procedure for accepted abbreviations. Sign each entry correctly, including date and time. An illegible signature may lead to all nurses on duty being named in order to “cast a wide net.” Date and time are crucial when creating a chronology of events.
  15. Take caution with frequent flyers. It is easy to spot staff’s judgment.The nurse applied oxygen on one patient complaining of an impending sense of doom and documented, “Patient recovered from her previous little episode.” It was the last entry before the patient died.
  16. Evaluate any new onset of pain.One patient suddenly complained of a new onset of debilitating headache after he fell and hit his head in the hospital.This is documented as a “migraine” although there is no previous history of migraines. 12 hours later, a CT scan revealed brain stem herniation.
  17. Hospital bills will be auditedfor items such as tubing charges, etc. to determine if policy and procedure was followed to prevent infections.
  18. Always use a disclaimer.Privacy issues include retaining back-up records for prescribed time and avoiding fax and e-mail when possible.
  19. The statute of limitation is typically 2 years.Medical malpractice casesmay be filed up to the end of these 2 years. It may take several more years before a potential case goes to trial. Hence, a nurse may still be testifying long after the events.

To avoid all these troubles, it is important that you pay attention to nursing documentation. It may not just save your patients' lives—it might save your career, too.

Do you have other tips to help out withnursing documentation? Tell us about them in the comments!

3 Comments

Categories

  • Top Viewed
  • View All Categories
Top View