Documentation Inservice

[CoffeeRTC, BSN, RN]

Does anyone have a great site or resource for an in-service?

We have so many issues with even the basics. We use PCC so it is either a skilled note or nursing progress note. Oh, the things I've seen!!

I was planning on doing a quick case study or chart review using a large screen and projector and projecting images of actual charted information and do a "what is wrong with this picture" and "what can we do better?"

Any suggestions?

[Golden_RN, MSN]

A few years ago I did what you describe. I took copies of poorly written notes, blocked out the nurse's names and projected them. As a group we reviewed them and rewrote them as a group (not really in the chart, just as an exercise). We focused on providing focused assessment info for change of condition charting because that was what we needed improvement on.

Additionally I handed out a cheat sheet for guidelines on weekly summaries.

I suggest some follow up audits after the in-service. Good luck!

[JKL33]

On 3/12/2019 at 3:59 PM, CoffeeRTC said:

projecting images of actual charted information and do a "what is wrong with this picture"

May I kindly but strongly suggest that you either find examples outside of your own company or else, even better, scrap the negative approach and simply review desired elements and provide examples of documentation that demonstrate such?

I'm sorry, I just think that unless done with extreme care and professionalism, publicizing a piece of an employee's work for the purpose of group critique is shaky ground; often entirely lacking in class/decorum. It is something people are only usually enthusiastic about based on whether they're in the chair or the lectern. Those in the chairs often find it neither exciting or "learning." It appears to be very difficult to pull this off without mockery arising, whether intentional or not.

Thanks for considering!

[Golden_RN, MSN]

21 hours ago, JKL33 said:

May I kindly but strongly suggest that you either find examples outside of your own company or else, even better, scrap the negative approach and simply review desired elements and provide examples of documentation that demonstrate such?

I'm sorry, I just think that unless done with extreme care and professionalism, publicizing a piece of an employee's work for the purpose of group critique is shaky ground; often entirely lacking in class/decorum. It is something people are only usually enthusiastic about based on whether they're in the chair or the lectern. Those in the chairs often find it neither exciting or "learning." It appears to be very difficult to pull this off without mockery arising, whether intentional or not.

Thanks for considering!

When I did this, extreme care was definitely used. We (management and educator) were very careful not to pick on anyone. One-on-one counseling was attempted first, but that approach was unsuccessful. If someone doing this type of training shares your concerns, it would be very easy to prepare mock case studies.

[Toadette, MSN, RN]

Instead of an incorrect note, can you find a few examples of stellar notes? I've used this strategy for group documentation teaching/in-services with the employee's permission and it works really well for me. I still block out patient identifiers and the nurses' names for the presentation.

This is a win-win, in my opinion; you've boosted someone's morale with positive feedback AND you're able to demonstrate exactly what elements of the note need to be included in the documentation.

[CoffeeRTC, BSN, RN]

On 3/18/2019 at 3:29 PM, JKL33 said:

May I kindly but strongly suggest that you either find examples outside of your own company or else, even better, scrap the negative approach and simply review desired elements and provide examples of documentation that demonstrate such?

I'm sorry, I just think that unless done with extreme care and professionalism, publicizing a piece of an employee's work for the purpose of group critique is shaky ground; often entirely lacking in class/decorum. It is something people are only usually enthusiastic about based on whether they're in the chair or the lectern. Those in the chairs often find it neither exciting or "learning." It appears to be very difficult to pull this off without mockery arising, whether intentional or not.

Thanks for considering!

I was planning on changing information so as to not identify the resident or the nurse. You are very correct, public shaming isn't professional or effective.

I've also started a collection of great nurses notes. We had a complaint visit a while back that was cleared very easily with a review of the nurses' notes.

[LTCO]

I have a question about the appropriateness of documenting statements from family members that were overheard. I've seen a lot of documentation that contains more subjective documenting rather than object, fact based documenting. Do you have any ethic protocol or training guides that I could provide for training?