As a new or seasoned registered nurse, there is a big focus in healthcare on the importance of nursing documentation. Documentation may seem burdensome, but is a necessary and integral aspect of the work done by nurses in all roles and settings. Learn more on the benefits of good documentation practice regarding a nursing care plan as we list what it is, why it’s done, and its importance.
What is Nursing Documentation and why is it important?
Nursing documentation is written evidence verifying that the nurse or healthcare professional ‘s authorized or moral responsibilities were met in order for nursing care to be assessed. Well-written, timely, and accurate documentation is an integral part of nursing practice, whether a nursing student, new nurse, or experienced nurse. It not only helps make the job easier for you, but helps open up the line of communication between the healthcare team and the patients.. Healthcare facilities and professionals should continue working together in order to continually improve their clinical documentation policies and systems. Below are some other reasons as to why a high-quality documentation standard is important:
- Improves communication among members of the healthcare team
- Helps providers pick up on information that might reveal other health issues for patients for better nursing diagnosis
- It is vital for research to learn more about issues in the healthcare field and improve healthcare jobs
- Documentation is used by insurance companies to determine reimbursement
- The credentialing department uses documentation to make sure facilities are practicing safe and quality patient care practices
Why Should You Be Documenting?
Today, there are an abundance of tasks that nurses have to complete – from electronic documentation of health records with multiple check-boxes, to overcrowded facilities, and long tiresome shifts. Nurses document their work and outcomes for numerous reasons. The most important is for communicating within the healthcare team and providing the proper patient information for other professionals. With nurses at the frontlines of patient care, the information they provide is crucial for the planning and evaluation of any medical interventions. Great documentation is accurate, factual, timely, and organized.
What Kind of Information Do You Record?
Let’s first begin by asking the question “if another nurse had to step in and take over health care for this patient, does my documentation provide sufficient enough information for them to do so?” Proper documentation from nursing staff or another healthcare provider should contain the following:
- Plan of care
- All aspects involved in the nursing process
- Admission, transfer, transport, and discharge information
- Resident educational background
- Any Medication Administration
- Collaboration with other healthcare providers and primary care given
Recommendations for Nursing Documentation
Nurses are the primary point of contact for patients, which means they have a great deal of responsibility when it comes to documenting accurate patient care in their medical record. Please refer to the below recommendations for your nursing documentation and how to improve your nurse charting.
#1 Be Accurate
Make sure to jot down information in real-time to avoid any nursing documentation error and harm to patient safety.
#2 Avoid Late Entries
Late entries can result in misinformation.
#3 Be Clear and Concise
Using clear and concise verbiage gives you credibility and authority. Make sure others can interpret your documentation without difficulty.
#4 Get Comfortable With Pre-Populated Boxes
When using an EMR, you want to try to use the options given as much as possible. Doing this will eliminate double documenting and allow for better data collection.
#5 Follow Policy on Abbreviations
Make sure to use the abbreviations that are standard to your employer. Don’t use obscure abbreviations that can be confusing to other people reading your document.
#6 Document Physical Consultations
Include the names, times, responses, and any actions taken when consulting all parties. These action items are critical in the case of an emergency or adverse event.
#7 Chart The Systems and the Treatment
Address both the symptom and treatment you administered and note it on the patient record.
#8 Avoid Opinions
Make sure to only write down facts, not opinions.
Nursing documentation is a crucial part of the healthcare field. A great nursing document is clear, concise, and accurate. It should detail all of the necessary forms of action you have taken to ensure patients are properly taken care of and members of your healthcare team are well informed.
Lonnie Brass, MAS Medical Staffing Travel CNA: Lonnie has been with MAS since November but has worked as a CNA for 12 years in a variety of different settings. He lives in the state of Illinois and the city of Joliet. When Lonnie has time outside of work he likes to spend his time reading fantasy novels, watching any and everything Marvel and experiencing the world and people around him.