How to report assessment findings?

[ekendall10]

We've been working on writing nurses notes in my clinical--normal and abnormal findings based on a head to to assessment. I'm still getting the hang of it, but in the mean time does anyone recommend a book or other resources for correct documentation?

Thanks!

[Double-Helix, BSN, RN]

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.

General rules:

Do's

* 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'ts

* 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.

Free and Free to Try Downloads for Nurses: Do's and Don'ts of Nursing Documentation