Documentation for Nurses: Best Practices

Raise your hand if you’ve ever heard, “If you didn’t document it, you didn’t do it.” If we had to boil down all of the best practices of documentation for nurses, this would be the golden rule.

What should you document? What is okay and what should be avoided? Why is nursing documentation so important? We’ll answer all of those questions and cover the do’s and don’ts of documentation in nursing in this article.

What Does Nursing Documentation Mean?

Nursing documentation refers to a nurse’s written or electronic additions to a patient’s chart. Practically every job you have will have its own set of required documentation for nurses, which will vary depending on the facility, role, and specialty.

For example, a nurse working in the intensive care unit (ICU) may be required to document physical assessments on all of their patients every four hours. A nurse working in the medical surgical unit may have this requirement once per shift.

What Is the Importance of Documentation in Nursing?

Nursing documentation is essential for communicating clinically relevant information to the healthcare team. It details nursing assessments and interventions, narrates changes in clinical status, states pertinent and relevant patient information, and provides evidence of care.

Many decisions are made based on nurses’ documentation. For example, a physician may review the nurse’s notes to evaluate medical interventions and the plan of care. A fellow nurse may compare previously charted nursing assessments with their current assessment in order to identify changes in patient status. These practices must also follow HIPAA guidelines to maintain patient privacy.

Documentation creates a record of services that is relied upon by payors (i.e. Medicare) for reimbursement of services. It may also be used as evidence in legal cases, reviewed for clinical research, and evaluated for quality assurance. Documentation is also often reviewed by certified clinical documentation specialists (CCDS), who verify the accuracy of information.

Timely Documentation in Nursing

While nurses typically have their entire shift to complete their documentation, it is encouraged to chart promptly. Remember, other healthcare members rely upon nursing notes. If a patient’s chart shows an elevated blood pressure, but the nurse has not made any notes addressing it, others may become concerned.

Additional charting requirements may arise depending on the patient’s status and diagnosis. If a patient received tPA, the nurse must perform (and document) neuro assessments every 15 minutes for the first two hours. Thus, nurses must be familiar with their facility policies as well as professional best practices regarding what type of documentation is required.

What Needs to Be Documented by a Nurse?

Simply put, everything a nurse does should be documented — from assessing a patient to calling the doctor to turning on a patient’s bed alarm. Examples of nurses’ documentation include:

• Patient head-to-toe assessments
• Change in clinical status
• Intervention and evaluation
• Patient and family education

Types of Documentation in Nursing

Most nursing documentation is implemented electronically in the patient’s electronic medical record (EMR), through programs like Epic charting. There are a few different formats and methods nurses follow when documenting, and some nurses use brain sheets to take notes on patients’ information. Common types include:

• Narrative documentation
• Progress note
• Charting by exception
• Situation, background, assessment, and recommendation (SBAR)
• Problem-focused documentation (i.e. SOAP)

Documentation for Nurses: Do’s and Don’ts

A nurse’s documentation becomes a part of a permanent record in the patient’s medical chart. Incomplete or improper charting can lead to serious medical errors and other consequences. You can help mitigate those potential outcomes by learning and following the best practices for documentation.

Do’s of Nursing Documentation

1. Include objective statements.
2. Use quotes.
3. Describe findings.
4. Document refusal of care.
5. Include timestamps.

1. Include Objective Statements

Relay your assessment findings in your nurse’s notes. Stick to the data. Record vital signs, physical exam findings, intake and output, and other measurements. Learn more about the difference between subjective vs. objective nursing data.

Example: Patient’s blood pressure measures 125/58.

2. Use Quotes

There are moments when it is important to record exactly what words the patient said. To make it clear that it’s the patient’s actual words, and not the nurse’s interpretation, use quotation marks.

Example: The patient said, “I cannot take that medication. Last time it made me itchy all over my body and it was hard to breathe.”

3. Describe Findings

Paint a picture with your clinical findings. Do not just say that the patient has a wound — describe it. Where was it? How did it look? What were the measurements?

Example: Ecchymosis noted on torso, blue and green in color, measures 1 x 2 in.

4. Document Refusal of Care

There may be times when a patient refuses care, whether a bath or medication. It is their right as the patient to accept or deny care. As the nurse, your duty is to record this interaction along with any other relevant information.

Example: Patient refused to be repositioned at 1600. Patient states, “I am comfortable just like this. I’ll let you know when I need help turning.” Educated patient on the importance of repositioning and tissue integrity. Patient verbalized understanding.

5. Include Timestamps

Timely documentation in nursing is pivotal. While the EMR will automatically timestamp documentation for nurses, it will do so for each entry, not when the event actually occurred. When making a nurse’s note, be sure to clearly convey the time symptoms appeared, when the doctor was called, when an intervention was implemented, and when the patient was reassessed.

Example:

• 0900 Patient reported pain of 6/10 to their right shoulder.
• 0910 Pain medication given, see MAR.
• 0945 Patient reassessed, reports pain has reduced to 3/10. Patient repositioned. Will continue to monitor.

Don’ts of Nursing Documentation

1. Don’t use subjective descriptions.
2. Don’t label patients.
3. Don’t chart for others.
4. Don’t document preemptively.
5. Don’t use improper medical abbreviations.

1. Don’t Use Subjective Descriptions

You don’t need to add your opinion or feelings about a patient’s status. When it comes to documentation for nurses, stick to the facts and let the numbers speak for themselves. Avoid vague terms like: large, bad, worse, small, less, little, and better.

Example: Patient’s O2 sat dropped very low.

2. Don’t Label Patients

Similarly, do not document your opinion, assumptions, or feelings of a patient. Describe their presentation, clinical findings, behavior, and gestures. When necessary, document quotations of their statements.

Example: Patient is a frequent flier and drug seeker who presented to the ER saying nonsensical things.

3. Don’t Chart for Others

Only chart what you have done and what you have observed. This means that you should not chart findings based on what you have been told — chart what you have found, assessed, and measured.

When you make a nurse’s note, you are attaching your name to it. Clearly stating who rendered care is of utmost importance in clinical documentation in nursing. Keep in mind that nurses’ documentation can include the name of another nurse who assisted in the patient’s care when necessary.

4. Don’t Document Preemptively

While it can be tempting to save time, only document things you’ve actually done or assessed.

Things can change in an instant. You may plan to give Tylenol to the patient in room 40, but until it’s been given, do not document it. You never know whether a patient will refuse a medication, spit it out, experience a decline in health, or have their orders changed.

5. Don’t Use Improper Medical Abbreviations

There are many, many abbreviations in medical terminology. Stick to universally accepted ones to avoid potential misunderstanding and subsequent errors. Refer to this “Do Not Use” list for terms to avoid.

Example: Patient received 2u blood. (Instead of “u,” spell out “units.”)

Put These Tips Into Practice

Using these best practices in documentation for nurses can help you become a better nurse. Looking for somewhere new to use these skills? IntelyCare can match you with nurse jobs in your desired facility type and specialty. Get started today.