Documentation help

[wksanjuan]

I was just wondering if anyone was willing to help me out by giving me an idea of documenting should look and sound like. I'm sure it's probably easy, but I'm a new nurse and would like to know, that way I won't get behind work trying to think of what to write.

For instance, if a fall were to occur, how would be documented? If you could also add other situations, please do. I just want to have a feel of what it is that needs to be documented so I make sure I cover my a**.

[TheCommuter, BSN, RN]

You might want to obtain the book Charting Made Incredibly Easy. It will probably be the best $25 to $32 you'll ever spend (even less if you buy it used or over the internet). There are too many situations regarding documentation for me to reasonably cover in one post. Another fine book is Surefire Documentation.

Basically, if I didn't witness the fall, I don't document it as a fall unless somebody definitely saw it with their own eyes or the patient is alert enough to confirm that they fell. I'll document it as a 'found on floor' unless the above conditions are met. I'll objectively describe the facts: the position in which they were found, any injuries noted, distance from the bed or wheelchair, any reports of pain, and whether or not the patient can tell me what occurred. If the patient is confused or demented, they are probably not going to remember what happened. Always include a set of vital signs and a neurological assessment with all unwitnessed falls.

Do not document that any patient is in pain unless you can also document any interventions that will lead to relief of the pain (PRN meds, positioning for comfort, relaxation, distraction, etc.).

Keep your personal opinions out of the charting. Do not use documentation as a forum to continue personal grudges against physicians, patients, family, supervisors, etc.

If a patient is making threats or badmouthing you or other staff members, document their statements in quotation marks: pt. states, "Your days are numbered, you stupid witch."

If a physician doesn't want to intervene for a patient in distress, document it in the most objective manner possible: Dr. Doe notified via telephone regarding pt's BP of 70/38 and pulse of 122. Pt. cool, clammy, and lethargic with moderate amount of blood in stool found on briefs. Dr. Doe states, "Continue to monitor. I'll see this patient in a couple of days."

[systoly]

Look for and attend a seminar on the legal aspects of charting. It will benefit you and your patients. The speaker should be a nurse lawyer. It's also a great little something to put on a resume or application.

[wksanjuan]

Thanks 'The Commuter' that was really helpful! Kudos!