Nursing Documentation-if you didn't document it, you didn't do it!

As I new nurse I have also struggled with the same concerns and questions as you regarding documentation. There is no clear cut and dry answer on what to document and when, and once again I feel it is up to your nursing judgement. For example, if I held a BP med after speaking to an MD I would write on the MAR "held per MD" and then initial and circle (as we do when we hold meds.) But for an infiltrated IV I would prob look at the site and depending on my judgement I may or may not contact the MD. But if I did contact the doc I would write a note, "IV site infiltrated, MD so-and-so contacted, MD in to assess pt, arm elevated on pillows and warm compress applied, will continue to monitor." I am learning more and more to document, but in a way that is smart and covers me legally, and I am becoming more comfortable with the process. Now, finding the time to document exception notes is always a challenge!

If we have IV infiltrate, we have to go online and fill out a "safety scoop".

You're right -- if you didn't document it, you didn't do it. So document, document, document! It will get easier as you gain experience, but even after 33 years I don't always get it exactly right. (Especially when working night shift, but that's a whole another thread!)

Document when you held a BP med -- not just that you talked to the MD, but which MD you talked to. If you don't know the name of the MD you're talking to, FIND OUT! Don't just hope your preceptor or the nurse sitting next to you at the station knows who she is! Especially in a busy teaching hospital, they may not know the MD any more than you do!

Any time the plan of care changes as a result of your discussion with a provider, document. Any time you note a new abnormal finding on your patient's assessment, document which provider you notified and what, if anything is being done about it. Any time you notify the provider of a significant abnormal lab result, document. For example, a K+ of 3.2 may not be "significant" if the patient isn't having ectopy and has an order to replace KCl -- but with ectopy and without replacement IS. A K+ of 6.8 may not be significant in a dialysis patient who is scheduled for dialysis today. In a patient with no known renal disease, it IS.

The more you chart, the easier it gets.

Chart everything. Safe > Sorry

Chart dr paged, what time and no return call times. Just write it on your papers. Also what your concern was. Going to court, they won't remember and will not back you up in most cases. Ours is easier, it's long hand say so and so was a bedside in regards to X, no orders received at this time. Or orders received see chart. As far as the med hold order if you don't document this under your patient note (computer charting or other place) you have no way of tracking it down. If you held it, you need to document the BP anyway, unless you have parameters on the chart. You'll get it but cover yourself.

I actually had a conversation about this topic with one of the seasoned nurses I work with. She was involved in a case many years ago. She has given me many help full tips. Like never write ERROR always write VOID and then initial the mistake. She said a lawyer told her that error always raises a huge red flag for them because looks ten times worse than void. She also told me never to chart in future tense. Ex: Will continue to monitor patient. Lawyers actually take this literally and think that means you will have an eye on the patient at all times. If you are supposed to be monitoring the patient and something happens then you will be held liable. She also said that she was also told that the rule of you don't document means you didn't do it is not neccesarily true because you can't document every single thing. We all know it's impossible. You should document the most important details. When you called the doctor, what interventions took place, etc.

I am finding time is my enemy, not enough of it. The charting, each Doctor and hopsital protical is different. How to remember and keep up with what to chart, do admission and continue patient care on 5-9 patients and be a fairly new grad. Overwhelmed, lucky to have a job and how long will it last? Call offs and shorthanded seem to go hand in hand? How long before I truly feel confident? I love the work with my patients.

Anyone have any recommendations on good books regarding documentation?
I could sure use some help too.
My mind seems to go blank when get my hands on the key board.

It's really not as hard as you all are making it. Just chart what you do, it's really not that hard. Always document any teaching that has been done. Some examples----

1) Notified Dr Smith of elevated BP 199/100. Received orders to adm clonidine 0.1 mg PO x1, administered med as ordered, see computer.
2) Inserted foley cath per dr orders using 16fr catheter, immediately obtained 300ml of amber colored urine, pt tolerated well, stat lock applied.
3) Notified Dr of low BP 95/59, no further orders received.
4) Notified Dr of low BP 88/49, received orders to bolus NSx1, administered as ordered, see mar.
5) EKG being done at bedside, will monitor results and notify physican.
6) Notified physian of abnormal EKG, no further orders received at this time.
7) Peri care given.
8) Instructed on use of incentive spirometer with return demonstration.
9) Instructed on s/s of hypoglycemia and to notify nurse if symptoms arise.
10) Removed 18g IV from left anterior forearm due to redness, swelling, pain,
catheter appears intact. Applied warm/cool compress and elevated.
11) 20g IV placed in left hand on first attempt, pt tolerated procedure with no complications noted.
12) PICC line dressing to left upper arm changed using sterile technique, site is without signs of redness/swelling.
13) Pt c/o chest pain and rates pain 9 on 0-10 pain scale, notified Dr Smith and recieved orders for morphine, EKG stat.
14) Turn and repositioned per turn q2h skin care protocol.
15) Applied barrier skin care cream to stage II on coccyx.
16) Dressing change performed to incision on left hip using wound cleanser and 4x4s, intact, incision without signs of redness or swelling.
17) Fall precautions in place, bed alarm activated. Instructed to call for assitance before ambulating.
18) Bolus tube feeding given per orders, zero residual, placement verified by auscultation, Jevity 1.2 given per peg tube and flushed with 150cc of free water.
19) O2 2LNC applied at this time due to low O2 sats.
20) Medicated with restoril for c/o insomnia and difficulty staying asleep.


Hope this helps, just some examples I thought of.