Amanda S. Gossman provides tips on keeping documentation up-to-date.
Nurses are talented and intelligent professionals, and our clinical skills, education and personal attributes are admired by many. These attributes need to be demonstrated at all times by our documentation principles.
This documentation conveys the care we have provided. Without it, our expertise is frequently judged in medico-legal matters.
Here are some of my hints for extraordinary documentation. These tips help me to reflect on the quality of care I provide as a nurse clinically, or in my case, work as a legal nurse consultant. I call it the Five Wise Men and the One Hardworking Nurse.
This refers to the patient. Whether I'm assessing them holistically at the start of a shift and throughout the shift, administering their medication or reporting changes in their clinical status, I always ensure that I verify that it is recorded into the notes of the correct patient. On occasion, I have found patients who share identical names, making for interesting discussions. Always remember to verify for yourself who it is that you are caring for and reporting about!
I often chuckle about the frequency of recording in patient notes. My rule is that whenever I have any contact with a patient, regardless of how brief and trivial the contact may seem to others, I record it.
I once made a note about a phone call a patient received, and noted the patient had a subtle, but obvious, change in mood shortly thereafter. Further investigation revealed the patient had been informed of a distressing social issue, and it explained the lack of determination from the patient to participate in their recovery program from that moment.
This prompted a social work referral, and what a difference it made! The skill of knowing when to document something that is different from the usual care regime is developed by a nurse over time, and with experience.
With sufficient mentoring and continued education, nurses are able to rationally make appropriate and timely notes in patient records. This sort of appropriate documentation indicates thought processes that are innate to nurses as patient advocates.
I fear that this is the tricky one of the wise men. Nurses are taught the conventional aspects of care to be recorded, such as medication rounds, doctor's visits and fluid balances, to name a few. Every nurse does this beautifully. It is appropriateness and English language skills that need further exploration in discussions on documentation.
Documentation is a form of communication and therefore implies that there is a reason why something is being documented. If you are writing a progress note, then you want to convey a message to someone, usually any staff member who is nursing the patient in your absence.
Everywhere that your institution specifies you are to document - with no exceptions!
Make time to document immediately after caring for the patient. It may be hard at first, but keep at it. Write clearly and don't convey your personal opinions about anything in your documentation.
Give your clinical impression followed by the action you have taken. Always read the notes written prior and don't rely completely on verbal handover to provide all the information needed about a patient.
Create your own style and quality that defines you. Have fun documenting.
Amanda S. Gossman, B Cur RN, B Cur (Hons) Critical Care, CNE.Do you have an idea for a story?
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