03.02 Documentation Basics

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Overview

  1. Documentation Basics
    1. Document objectively
    2. Be reflective of the Nursing Process
    3. Document in real time
    4. Be legible
    5. Charting by exception

Nursing Points

General

  1. Documentation Basics
    1. Document Objectively
      1. Document what is seen
      2. Use quotations when using subjective data
      3. Be clear, concise and complete
    2. Be Reflective of Nursing Process
      1. Nursing terminology
        1. SOAPIE, ADPIE, APIE
        2. Use the acronyms to help guide charting
      2. Be Sequential
        1. Chart things in the order you give the patient care
        2. Don’t skip around
    3. Document in Real Time
      1. Time Stamp
        1. Chart as close to when the care occurs
        2. If this is not possible, be sure to include a time/date that care was done.
        3. Some computer systems don’t allow for time stamps or nurses notes
      2. Sign and Date
        1. To solidify documentation, sign and date all necessary docs
    4. Be legible
      1. If using paper charting, write neatly
        1. Including your signature!
      2. Use facility approved abbreviations
        1. TJC Do Not Use List
      3. Use appropriately colored pens
    5. Charting By Exception
      1. What is CBE
        1. Method to quickly chart
        2. Only document what’s abnormal
        3. “Normal” will be pre-defined
      2. Follow Facility Policy

Nursing Concepts

  1. Communication
  2. Health Information Technology

Reference Links

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Video Transcript

In this lesson, we’re gonna take a look at some basics in documenting care.

When we document anything in the patient’s record, we need to document objectively. What do I mean?

You want to say what you see. Not what you speculate, or think, but what you literally see.

Let’s say your patient falls out of bed, and you come in and they’re on the floor. You wouldn’t write “Patient fell out of bed,” because you didn’t witness the event. You’d say “Observed patient on floor. Pt states “I fell out of bed.””

Which leads me to my next point. When the patient says something about what they experienced or see or feel, use quotes and say “Patient says…”

Be clear, be concise and be complete. Don’t ramble with your documentation. Make the point, and move on. Include only what information is witnessed and important.

Another thing you’ll want to do with your documentation is to reflect the nursing process.

If you take a look at the nursing process lessons and the way we move through the nursing process. Your programs will determine which terminology, like SOAPIE, ADPIE, or APIE you use, but use that terminology to help guide.

You’ll first document your assessment or the complaint, then you’d act based on what you think is going on, and document those actions. For example, “BP is high, provider notified, new orders received. Medication given per order. Will continue to monitor” You’ve just documented that you assessed, you analyzed the situation, you realized you needed to get a new order because the patient needed a new blood pressure med, and then you delivered care. You’d also follow up to make sure the intervention worked.

One other thing you’ll want to do is be sequential. Chart things in the order you give care. If you gave a bed bath before you changed linens, then document it that way. Don’t hop around. Like in the legal lesson, if your documentation is ever called into court, you want to be able to say “I did this and then this and then this and I did them this way because…” This shows that you provided solid, rationalized nursing care based on your nursing process.

When it comes to signatures, a lot of electronic health records allow for automatic time stamps. If your system allows you to do that, then great. Some systems don’t, so just check to see how the system you’re using verifies the time and date.

When you chart, be sure to chart as close to the time that you give care. We talk about some ways you can’t take notes or memory aids to help you come back later, but check out the pro-tip lesson for that. The reason you don’t want to delay charting is because sometimes gaps in memory (especially if you go home and sleep!) can contribute to omitting information, which could be crucial to your charting.

One other thing – sign and date everything that needs a sign and date (or initials). And sign legibly. You want to basically show everybody else that you approved your documentation.

Ok, another thing you want to do when you’re charting is to be legible. As great as technology is, not everyone has switched over to an electronic health record, and some people use paper charts. Make sure that anything you write is legible. Write neatly, including your signature. The other thing you want to do is use blue or black ink. If something needs to be photocopied, other colors may not show up, so you want to make sure that whoever has a copy of your care shows that you actually did it. Writing in pink or purple in an official medical record is just inappropriate. SOME facilities request red ink for acknowledging provider orders on paper, but otherwise it should always be in black or blue.

In documentation, abbreviations are often used. Make sure that you are using facility approved abbreviations and more importantly, make sure you are following The Joint Commission’s recommended Do Not Use list. The Do Not Use list is a list that has common abbreviations or symbols that cause confusion and often lead to errors. So don’t use anything on that list – there’s a link for it in this lesson.

One other thing I want to talk about is Charting By Exception, which Charting By Exception is something you’ll hear a ton of when you’re talking about documentation.

So what is it?

Well Charting By Exception is a quick way to chart, it’s like a shorthand for documentation. What you basically do is only chart what’s abnormal. For example, if your patient’s lung sounds are clear, you don’t have to document “Lung sounds – clear.” You don’t have to document what’s normal, only what’s abnormal. Normal values will already be defined, usually by facility policy.

Check with your facility because every hospital has different rules when it comes to charting by exception. Some say that you have to document WDL (or within defined limits) in your first assessment for the system or some say that if it’s normal you can just leave it blank. But CHECK WITH YOUR FACILITY first.

When discussing the basics of charting and documentation, we look at the nursing concepts of communication and health information technology.

Now to recap:

When you document, document objectively. Chart what you see and what the patient “says”

Reflect the nursing process when you chart; it helps keep you on track.

Be legible and don’t use unapproved abbreviations.

Sign and date your documentation to show you looked at it and approve it!

When you can, and when it’s applicable, chart by exception to save yourself some time.

That’s it on for our lesson on documentation basics. Make sure you check out all the resources attached to this lesson. Now, go out and be your best selves today. And, as always, happy nursing!!

Read more

  • Question 1 of 5

A nurse is caring for a client who has experienced a head injury. The nurse is performing a focused neurological exam and documents that the client’s mental status is obtunded. Which best describes a client’s affect as obtunded?

  • Question 2 of 5

A nurse is administering platelets to a client with leukemia. After completing the transfusion, the nurse should document which information?

  • Question 3 of 5

A client who is in the hospital to deliver a baby does not speak English. The nurse attempts to call for an interpreter but the client refuses to use one. Which information would the nurse document in this situation?

  • Question 4 of 5

A client with bipolar disorder is taking prescribed lithium while in the hospital. Which information would the nurse need to document while the client takes this drug? Select all that apply.

  • Question 5 of 5

A client who received a unit of packed red cells suffered a transfusion reaction. The nurse followed the appropriate steps to manage the reaction. What information is required for the nurse to document in the client’s chart? Select all that apply.

Module 0 – Fundamentals Course Introduction

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