One of the first things you probably learned in nursing school and as a new nurse is the importance of documentation. Accurate and appropriate documentation is key to ensuring accountability for nursing care and proof that protocols and procedures were followed correctly. In order to protect yourself liability-wise, you need to take documentation seriously and make sure you do it correctly. Here are a few tips to improve your nursing documentation at work.
- You’re Never Too Busy For Documentation
It can be easy to think that you are too busy to sit down and document, or procrastinate documenting, but these are the times when documentation is at its most necessary. For example, during times where there are codes, transfers, verbal orders from superiors, abnormal vitals in patients, or orders for medication, you are probably very busy with taking care of these immediate demands. Don’t forget, though, that documenting these moments will help you make sure you do everything correctly.
- Reporting Critical Lab Values
Critical lab values require immediate intervention because they could be life-threatening to the patient. Therefore, these values need to be reported to the appropriate nurse within 15 minutes of receiving lab reports. Following that, the nurse has thirty minutes to report these critical values to the physician. Documentation here is crucial because the timelines are so strict.
- Be Specific
When documenting assessments and other notes, avoid general language since this could lead to unnecessary confusion. Instead, be specific when indicating the who, what, when, where, and why of the thing you are documenting, if applicable. For instance, instead of documenting that “Dr. Jones called today,” you should indicate why he called, exactly when he called, what he said, who needs to be informed, and what the follow-up action is.
- Know the Guidelines
Most healthcare facilities have specific guidelines for documentation. Paper documentation and charting should be done legibly in blue or black ink and should be free from spelling and grammatical errors, as well as erasures or white-outs. Above all, it should be objective and accurate.
- Indicate Allergies
One thing that is easily overlooked by nurses when filling out patient charts is the presence of any allergies. Indicating this on the chart is vital for ensuring patient safety and preventing undue damage to the patient.
- Follow the Timeline
Charting is very time-specific. It should not be done in advance, as this indicates values that may not be accurate at that time. Likewise, if there simply was no time to complete the chart at the time, late entries need to be entered according to facility policy. Similarly, any corrections to charts already completed should be approved and entered.
- Beware of Patterns
If your documentation or patient charts all tend to look similar and too perfect, they may be called into question. It can be tempting to fill in charts by simply using the basic information available but overlooking simple things like whether a patient is a fall risk is a common mistake. As you fill out charts, be thorough and note down any and every unique instance of the patient’s circumstance.
- Use the DARE Approach
If there is any change in the patient’s condition, documentation should be taken to identify if staff were notified, who they were, and what steps were taken to help the patient. When in doubt, use the SBAR approach: situation, background, assessment, recommendation. All of those items must be documented in the patient’s chart to ensure that the right next steps are taken.
- Know Appropriate Abbreviations
Documentation can be quite tiresome since you’re doing it all day long. You’ll probably find yourself writing down the same words over and over, which can become a bit mind-numbing. Before you start shortening words on your own, take care to understand the common medical abbreviations that are accepted at by your facility’s policy. This will prevent you from having to redo whole charts.
- Pay Attention to Previous Documentation
You’ll often have to be looking at the documentation taken by other nurses, especially during shift changes when you take over for another nurse. You’ll need to look at the documentation he or she left and decide where to go from there. One thing to be cautious of is any bias in the previous staff’s judgment of the patient or situation. Try to go in unbiased and complete care of the patient to the best of your ability, regardless of the previous nurse’s experience.
- Include ALL Medical Procedures and Devices
Often, a hospital bill may be audited to see if procedures were followed correctly. The hospital bill will indicate which procedures were done and which devices, medications, and other implements were used. Documenting all of this on your own as well can stand as alternative proof that a procedure was followed properly.
- Remember Privacy (HIPPA)
Keeping good documentation means that you do it in a way that preserves the privacy of the patient. This means that sharing records with other necessary parties needs to be done in person; email and fax should be avoided as a way of sharing records with others since they could easily be intervened by outside parties.
Final Thoughts
Proper documentation is key for everyone’s safety, from nurses to doctors to patients and their families. By following the above tips, you should be able to improve your daily documentation and charting in a way that will make your work life easier.
