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Part Three: New RN guidance: So I am a Nurse, now what? (Proper Documentation)

Updated on May 2, 2016

Proper Documentation as a New Nurse

The next blog is about proper documenting. If you ask any nurse in a hospital or even in home care about what they do the most during their shift, he or she will reply without hesitation, documenting. So, if documenting takes up the majority of your day, why not document correctly and efficiently.

First, set up a document schedule for your day. Some nurses wait till the end of shift and document the whole shift at this time. The concern with this type of schedule is you may lose vital information to document. If you lose one scrap of paper that needs to be documented in the official record, where do you go from there, especially if you do not even remember you missed it? Document the initial assessment early in the shift. Why early, well that is twofold. First, you set a great foundation for your shift, the bulk of your typical day of documenting is completed, plus you do not need to remember things or find scraps of paper at the end of the day. Second, you do not confuse what was the initial assessment and what were the changes throughout the day. Documenting needs to be accurate, and it also needs to be in the correct order of events. Get the initial documenting done early. Some say, I do not have time to accomplish it, but if you look at your day objectively and see where your time is lost and found at the beginning of the shift, you will find time gaps to accomplish this goal. Time management is key to a successful nursing career. Better time management means less stress, a very important aspect to nursing.

Now what to document? The shift assessment sets the foundation for the shift. Still, use critical thinking when documenting. I have seen nurses document everything is within normal limits, but the patient is still in the hospital. If the patient’s documentation depicts a person healthier than you and most of the county, why are they in the hospital? One thing I have noticed in documenting, is nurses thinking the patient’s pulmonary function is within normal limits, but the patient is on oxygen. Critical thinking and great observation skills are needed to be a successful documenter. Most facilities or companies document the abnormal, and if it is normal, they do not document. That idea is fine, adhere to the policies of your facility or company. With that said, I have noticed documentation duplication. The nurse goes through the initial assessment and documents and then the nurse writes a narrative about the shift assessment they just completed. Does that mean the assessment cannot stand alone, it needs a narrative to complete the documentation in this example (both forms of documentation are telling the same assessment story)? Not only should you documentation be accurate, it should also be succinct. Develop good habits in documenting, and you will find when you leave your shift or go off duty, you will feel less stressed and spend no time looking for scraps of paper that are reminders for you to document. A side note, by the time it takes you to write out reminders and keep them organized, you could have had those assessments and changes already documented in the chart.

There are some things I notice that nurses fail to document or document incorrectly. First, I have noticed that nurses forget to document when they talk to physicians and mid-levels. Those conversations are crucial and should have a note in the chart. Here is an example of a patient who had a critical level PTT (on a heparin drip), the nurse said she called the doctor and the doctor told her to continue the infusion and see what the next PTT would be. Well, that patient developed a cerebral hemorrhage an 3 to 4 hours after the blood draw and no documentation about that call to the physician was noted anywhere (the shift ended for that nurse too). The physician denied the conversation and there was no proof in the chart the call was ever made. If it is not documented, it did not happen, so document conversations with physicians and mid-levels. Next, is how to document. A nurse sees a patient on the floor in the hospital room and the nurse writes in the chart, the patient fell and nurse helped back to bed and contacted the doctor. Now, take a look, by saying the patient fell would indicate that the nurse saw the fall in progress. If the nurse just saw the patient on the floor, state such, do not add anything to the narrative. I have heard of patients wanting to sit on the floor because of the coolness of the tile, strange but true. If the nurse did not see the fall, the nurse should not add the fact the patient fell in the documentation.

Documenting is a crucial aspect to nursing, but by charting correctly and succinctly, it will not be the aspect that brings you stress or an early retirement.


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