How can I get better at documentation?

[Nurse Beth, MSN]

You get better with focused practice, and you can do this. I have no doubt that you can become excellent at documentation with a structured plan. 

Documentation is essential to patient safety, handoff, and insurance reimbursement.

Can I say your supervisor did not help you by criticizing you or your education. Ask your educator for help if you have one.

• Read the provider's notes every time they see your patients. You will begin to see what concise objectivity looks like. Notice what they include and what they don't. Note: Many providers were trained to use SOAP (subjective, objective, assessment, plan), and the Joint Commission now recommends SBAR (situation, background, assessment, recommendation). You can still learn a lot by reading the provider's notes trained under either format.
• Be objective. Stick to the facts and avoid assumptions or personal opinions. Describe what you observed or were told without adding interpretation. This helps maintain the integrity and accuracy of the documentation.
• Include relevant details. Document pertinent information such as the resident's medical history, any pre-existing conditions, medications, vital signs, and changes leading up to the event.
• Use clear and concise language. Avoid medical jargon and complex terminology unless necessary. Write in a way that anyone reading the documentation can understand, including non-medical personnel.
• Document in real-time. Try to document events as they happen or as soon as possible afterward while the details are fresh in your mind. Waiting too long can lead to inaccuracies or omissions.
• Follow guidelines and policies. Familiarize yourself with documentation standards, protocols, and policies specific to your healthcare facility. This ensures consistency and compliance with regulatory requirements. There may be certain forms for certain situations, such as code sheets, transfer forms, or death packets.
• Use a structured approach. Organize your documentation clearly and logically. Start with basic information such as date, time, and location, followed by a chronological account of events.
• Review and revise. Take the time to review your documentation for completeness and accuracy. Make any necessary revisions or additions to reflect the events and care provided accurately.
• Seek feedback. Ask a more experienced colleague or trusted supervisor to review your documentation and provide constructive feedback if possible. Learning from others can help you identify areas for improvement.
• Reflect and learn. After completing documentation, take some time to reflect on the experience. Consider what went well and what could be improved for future situations. Continuous learning and self-improvement are essential in healthcare.

SBAR 

SBAR is recommended as a framework for clinician communication, as in calling a provider or giving report. However, it's also used partially or entirely in documentation. The components of SBAR are as follows:

• Situation: Clearly and briefly describe the current situation.
• Background: Provide clear, relevant background information on the patient.
• Assessment: State your professional conclusion based on the situation and background.
• Recommendation: Tell the person with whom you're communicating what you need from him or her in a clear and relevant way.

Situation

Resident's Name: [Provide the resident's name]

Time of Incident: [Specify the time when the incident occurred]

Background

Resident's Condition Before Incident: [Describe the resident's condition before the incident occurred, including any relevant medical history or recent changes in health status]

How Resident Was Found: [Describe how the resident was found, including any observations about their appearance or behavior]

Assessment

Immediate Actions Taken: [Detail the immediate actions taken upon discovering the resident, such as initiating CPR]

Response to CPR: [Describe the resident's response to CPR, including any changes in condition]

Recommendation

Next Steps: [Provide recommendations for ongoing care or any follow-up actions needed]

Communication with Medical Team: [Recommend informing the medical team about the incident and the resident's current condition]

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SBAR Example (tweak with your specific details)

Situation

Resident's Name: John Doe

Time of Incident: 10:00 PM

Background

Resident's Condition Before Incident: John Doe, a 75-year-old male, had a history of hypertension and diabetes. He was stable earlier in the shift.

How Resident Was Found: John Doe was found unresponsive in his room by the nursing staff during routine checks. He was not breathing and had no pulse.

Assessment

Immediate actions taken: CPR was initiated immediately upon discovery by the nursing staff.

Response to CPR: Despite efforts, there was no return of spontaneous circulation.

Recommendation

Next Steps: Notify the attending physician and family members of the resident's passing. Prepare the resident for transfer to the morgue as per facility protocol.

Communication with medical team: Inform the attending physician and document the incident in the resident's medical records for review and future reference.

Conclusion

Remember, improving documentation skills takes time and practice. By implementing these strategies and seeking support from colleagues or mentors, you can enhance your ability to document patient care experiences effectively.

I commend you for looking to improve your skills.

Best wishes,

Nurse Beth