Documentation really depends on your facility's policy and procedure. Every place I have worked or been to clinical, the documentation system was different. Some used paper charting, a few used electronic documentation, but even the three locations that used EMR did not use the same system.
For my nurse's notes, I find that the most helpful thing to do is have a blueprint of my assessment and sort of fill in the blanks. When you write a note, follow the same format each time. Break it down by system and then by individual details in each system.
Do'sFree and Free to Try Downloads for Nurses: Do's and Don'ts of Nursing Documentation
* Check that you have the correct chart before you begin writing.
* Make sure your documentation reflects the nursing process and your professional capabilities.
* Write legibly.
* Chart the time you gave a medication, the administration route, and the patient's response.
* Chart precautions or preventive measures used, such as bed rails.
* Record each phone call to physician, including the exact time, message, and response.
* Chart patient care at the time you provide it.
* If you remember an important point after you've completed your documentation, chart the information with a notation that it's a "late entry." Include the date and time of the late entry.
* Document often enough to tell the whole story.
* Don't chart a symptom, such as "c/o pain," without charting what you did about it.
* Don't alter a patient's record - this is a criminal offense.
* Don't use shorthand or abbreviations that aren't widely accepted.
* Don't write imprecise descriptions, such as "bed soaked" or "a large amount."
* Don't chart what someone else said, heard, felt, or smelled unless the information is critical. In that case, use quotations and attribute the remarks appropriately.
* Don't chart care ahead of time - something may happen and you may be unable to actually give the care you've charted. Charting care that you haven't done is considered fraud.