How to document

  1. 0
    Hi, i am a new nurse with only 7 months in practice. I am so terrible when it comes to documentation. I think and think how to document. At school we did not enforce documentation as much, we talk about it but not to much in details. My question is how would u document something that a x patient writes because in nonberbal, how would u document that in a nurses notes? Would u document exactly as pt writes it? would u use " ", Etc. Every day, every night i think about it and i am worry i may get in trouble if i do not document correctly! Any suggestion, comment or input will be very appreciate it. Terrified i do not want to japorize my career.

    Get the hottest topics every week!

    Subscribe to our free Nursing Insights newsletter.

  2. 11 Comments...

  3. 1
    Be objective. State the facts, not your opinions. Look at other nurses documentation and learn from it. There are books on this - also try YouTube.
    psu_213 likes this.
  4. 0
    I am a home health nurse. I frequently communicate with my patients' parents via text. I document what they say verbatim, in quotes.
  5. 0
    Ok thanks, if my patient is nonberbal and py writes something i would document it using quotes ! Correct?
  6. 1
    Quote from Dragonstrike
    Ok thanks, if my patient is nonberbal and py writes something i would document it using quotes ! Correct?
    The only things I would worry about placing in quotations would be complaints, refusal of care...anything that would be documented exactly as said if they were able to speak.
    Dragonstrike likes this.
  7. 2
    I would. I would write. "Used whiteboard to communicate this shift. Wrote "I have pain 7/10." PRN Tramadol given with good effect."
    Meriwhen and Dragonstrike like this.
  8. 3
    It would be helpful if you began practicing here. We don't do txtspk on AN. And it will definitely not be OK to use it in charting.

    As to how to document in general, your aim is to communicate what you find and what you did over your period of responsibility. I always found it easier to be organized if I did it head to toe using systems:
    Subjective: What the patient says. "I'm feeling really lousy." "My headache is better." "I don't understand why I have to take all these pills." "I can't catch my breath." Whatever.
    Objective: VS, I&O last shift, today's weight, general description of pt as you found him "Received sitting up in high Fowler's, denies discomfort,
    CNS, including level of consciousness, orientation, ability to communicate, pain/meds/results, affect (fear, anxiety, relaxation...)
    Chest: Cardiovascular- heart rate and rhythm, BP, indicators of peripheral circulation, etc., IVs, TEDs/SCDs
    Lungs: Airway, breath sounds, cough adequacy, secretions, effort of breathing, ABGs/SpO2
    Belly: NPO/diet, appetite, swallow, bowel sounds, BM, tubes/drainage
    GU: Urine output/color/frequency/route; reproductive if appropriate
    Ortho: posture, deformity, joints, positioning, splints, CPM; activity, walking, turning, out of bed
    Integ: Wounds, healing, dressings, drainage, pressure points, aids to relieve pressure
    Tests/MDs/etc. "Seen by Dr X, psychiatry." "PT in for instruction on crutch walking." "CDE in with instructions for insulin and BGM."

    If you note this at the beginning of your shift, you just need to update the high points as you go along. Helps you keep your mind organized.
    Greenclip, Meriwhen, and Dragonstrike like this.
  9. 1
    You can also document observations. For example: facial grimace observed with repositioning, patient protective of right arm with movement.

    If you document how a patient appears, it is important to list specifics. For example: patient appears anxious; aeb rapid speech pattern, RR elevated from baseline, restless, tense posture.

    See if your place of employment has a list of acceptable abbreviations and a preferred documentation format (negative charting, charting by exception etc).

    It also helps me to stick with a general format for my different types of progress notes, that way I make sure my notes are organized and I don't forget anything. When I document a general assessment (new admit, change of condition etc) my general format is: A&Ox. Skin signs, turgor. Pain, generalized c/o. Respiratory Assessment findings. Abdominal Assessment findings, intake. Output. CMS/ ROM. Once you figure out a format, it makes it so much easier. Also, ask for feedback from your supervisor.
    Dragonstrike likes this.
  10. 0
    Thank you every one for your suggestions! I am worried because i was assigned a pt who does not talk or interact and one particular day after i introduced myself, pt wrote a name that it was not his/her name so i did not know how to document it. I have been asking my supervisor for feedback or if we can go over my notes, or if she can give me any advice, but supervisor is very busy, never has time or she will not call back! So i feel fustrated because i want to do my job right and i do not want to put my license in danger!
  11. 1
    I would always skim through the patients chart to see how the physicians, nurses, social worker etc would document anything ...and take my cues from that...but I would check with my nursing supervisor/manager to make sure what I was doing was correct /.....miscommunication is not a good thing to have between a patient and their nurse. watch for body language, facial expressions, nodding and shaking of the head...if they answer yes or no when you ask questions document how they answered you. Hope this helps.
    Dragonstrike likes this.

Nursing Jobs in every specialty and state. Visit today and Create Job Alerts, Manage Your Resume, and Apply for Jobs.

A Big Thank You To Our Sponsors