new grad needs help with documentation tips

  1. I need help with documentation skills like what to document and not want to document. What is safe and what is not safe. Particulary when each shift do their outcome summaries. I already know the biggest thing is that if it is not documented then you did not do it although you really did do it. I work on a surgical care floor for those who don't know.

    Thank you.
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  2. 10 Comments

  3. by   webbiedebbie
    I was trained in head-to-toe assessment. It has become routine for me. That way, I don't forget to chart anything. Always document things from the norm. If you call a physician, document what time and what you spoke of (for instance: Dr. So-and-so paged. Report given regarding such-and-such. Orders received and implemented), or along those lines. If a patient falls, document "patient found on floor next to bed in a sitting position. Siderails up x 2 on bed. Patient reports such-and-such." Document what you did for the patient.

    Really, check with your floor for documentation policies.

    We use PIE charting. Problem...implentation...evaluation. This includes the careplan in our charting.

    Hope this helps.
  4. by   altomga
    Document everything! Of course document your assessment of the patient. Document any change from initial assessment. Even when you page a doctor; if they don't return your first page, docuement that, document that the charge RN is aware of any problems with the patients or doctors. If you don't get orders from a doc, chart " Dr. Jones notified of.......no orders recv'd at this time, or Doctors chooses not to draw any labs at this time, etc. We normally suggest things to the doctor that we would believe needs to be done and if they say NO I chart that they chose not to, but it gives the understanding that I knew that it should've/could've been done. Always chart so it would save you A$$ later on if something were to happen with the patient. My charting has answered many questions at times when my manager asked me "what happened", I tell her to read my notes!
  5. by   purplemania
    Our facility offers one whole day of documentation training to new grads, included in our 6 wk orientation. Does your Ed. Dept. have training videos? Are you working with a preceptor? Read your policy right away and read as many charts as you can. Ask questions!!!!! How scary for you to document without guidelines.
  6. by   moonshadeau
    As you go along, you will see those who chart really well and those who do not. At my facility we use documentation by exception. Documentation is done by normal and abnormal. Assessments that are normal receive a check mark and abnormal recieves an asterisk and requires a note. Subsequent assesments can have a check or a greater than sign following a previously charted abnormal assessment, or a new asterisk sign.

    The system is great in theory, but it can become habit to "follow" assessments from previous shifts. I make it a habit to write a note on every chart of each patient I care for. (a little hard on NOC's with a 1:10 ratio) But for each note, even a one sentence lung or cardiac status will help me remember the patient in the future if questioned.

    Also remember to chart what you have taught the patient or family. I agree too that when discussing a patient condition with a MD to document. Many times I have had a MD ignore a patient condition, but by charting "MD.D notified at 0000 of pt. X current status. Discussed .... No new orders recieved." Can potentially save your rear.

    I ask the question too, Do you not have a preceptor to show you the ropes? This is the kind of thing that a preceptor should be teaching you as every facility has its own "need to document" quirks.
  7. by   txsugarlvn
    Western Schools has a CEU course available to teach documentation skills. Always chart thoroughly. It's the best protection you have in case of litigation or questions regarding your care or the patient's treatment. Read your facility guidelines for documentation to be sure you are within the boundaries they have established. If you have any questions, ask your charge nurse or preceptor for clarification. If in doubt, write it down anyway to be sure. It's better to have more info than necessary than not enough and leaving it open to interpretation.
  8. by   PsychoRN
    The 3 most important things I learned in nursing school were:

    1. Cover your a$$
    2. It wasn't done if it wasn't documented
    3. Someday you may have to defend your charting in court
  9. by   petiteflower
    You should be able to look back at your documentation and be able to tell the "complete patient picture". Get in the habit of reading your charting towards the end of the shift and making late entries to correct any errors or omissions. What I see commonly, and what our docs complain about is activites, up in chair etc. charted, but, how did patient look? For example--Pt up in chair for meal, skin pink warm and dry, respirations without distress. Pt offers no c/o at this time. Or Pt resting quietly, eyes closed, skin pink respirations visible, even and regular. rather than, Pt up in chair. No c/o, or Pt sleeping. If you see something describe it--foley present, urine clear no foul odor. Size of wound, steps to dressing change. ETC.

    Also develop your own style. Everyone charts a little different. Do what you will recognize in the future. Experience will tell you what you need to expand on and what you need to just note. You can also ask the docs you work with--if you feel comfortable--if there is anything that you are leaving out. (That is if they read the nursing notes--they don't always)

    Hope this is helpful.
  10. by   gizzy76
    One small piece of documentation information I found was

    If you fill out an incident report, do not record it in the patients chart. Also, do not put on the incident report that it is recorded in the patients chart.
  11. by   Agnus
    Originally posted by petiteflower
    , but, how did patient look? For example--Pt up in chair for meal, skin pink warm and dry, respirations without distress. Pt offers no c/o at this time. Or Pt resting quietly, eyes closed, skin pink respirations visible, even and regular. rather than, Pt up in chair. No c/o, or Pt sleeping. If you see something describe it--foley present, urine clear no foul odor. Size of wound, steps to dressing change. ETC.

    Thanks for this valuable reminder.
  12. by   charissa
    One thing i hate about starting as a new employee at a hospital, even as an RN with experience, is that everyone does things differently and preceptors you work with can be great examples or horrid role models. You just need to find you niche, but document to cover yourself, because when it comes down to it you are all by yourself during a deposition

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