Nurses: Did you find learning to document a difficult task?

Documenting adequately is absolutely essential. You would not be unwise to take a class to learn more, as this piece of nursing has been made tedious and over-involved, but it remains central and essential to the profession.

Charting allows us to follow trends on patients. We can watch subtle changes in their condition by recording vitals, I&Os, meds, etc. It allows us a window into the physiology of each unique body, which is indispensable to nursing. I have had experienced nurses come up to me, look over my shoulder at a patient's I&Os and vitals and cluck their tongue in concern. And guess what? They were right! Trouble was on the rise, and they could see it just in the data.

Legality is another area that documentation covers. I'm sure you've heard by now that "if it wasn't charted, it wasn't done". It's very true. Legally speaking, charting covers your behind in the event that something bad happens. Knowing how and what to chart can only help you in your career.

Charting can also help the patient if done correctly as well as accomplish the two goals above. Example: I have known nurses who have adamantly refused to document "bad behavior" on the part of the patient. I used to work oncology, and on occasion, we'd have patients get angry, as is a normal step in the process of accepting a new diagnosis and coping with treatment. Every now and then, they'd take it out on staff.

Let's be clear: documenting an event like the one above is not an act of retaliation against the patient. Far from it, in fact, which I believe was the point that my coworkers were missing and part of the reason they didn't chart patient outbursts--they didn't want to be accused of charting out of spite.

However, when a patient acts out in anger, that is an important testament to their emotional and psychological state of mind and a valid part of the nursing assessment. Even if my patient's outburst is a one-time thing and they were just upset and overreacting, you bet I chart it. It not only goes to record the incident in case of a review thus covering my butt, but more importantly for that patient, documentation of those incidents can help cue the physicians and other services that perhaps mental health/counselors may need to be involved, especially if it is an ongoing issue. I had a patient get consulted by mental health once because I charted that kind of an event. I also had a patient get prescribed an antidepressant because I constantly charted her withdrawn, extremely sullen behavior, which raised alarm amongst the physicians and led them to follow up with psych.

I don't mind charting. I like to write and am usually pretty good at documenting my observations in an objective manner. I'm also an extremely fast typist, which doesn't hurt any!

Documentation should be part of your nursing school ciriculum at some point. I took the 6 hour side documentation course and it didn't add anything new. Where ever you end up working will have their own documentation requirements, which you will learn.

i put taking a class on documentation right up there with managing respiratory emergencies

take it

Is documentation a part of your nursing curriculum? Are you regularly measured or graded on your documentation? If that's the case, I can't imagine a separate course would be helpful. I have been in healthcare and medical records (transcription, billing, management) for 10+ years and nursing documentation is definitely different. I did feel that my classes and clinicals were very clear in what was excepted though and my instructors did score us and evaluate our documentation often.

Is there another course you could take to fill in your schedule so you would be full-time? I do understand that being a benefit but I don't want you wasting your time if your nursing classes are already providing you with that information. If they are not providing you with the information and are expecting you to already know it, then yes, the class may be helpful. Good luck!

One of the very best compliments I ever rec'd from a physician was that he loved my documentation because he could really see what the patient looked like by reading it (bless you, John Mehigan, vascular surgeon, wherever you are). That is what you are aiming for.

The best way to think about nursing documentation is to think first about what medical records are used for. Quick! How many things can you think of?

1) Communications between staffers and disciplines

2) Legal documentation of events, assessment, and care

3) Supporting billing

4) Clinical research

5) Education

6) Quality improvement/risk management

Gold star if you can think of some more!

The point is that you have to keep a lot more in mind when you write your notes and document your meds. All of those folks will be reading them sometime and counting on you to be accurate and descriptive. If your class has that in mind, by all means, take it and use it every day. If it doesn't, consider a creative writing class that teaches you how to see beyond the obvious and how to use good English to describe it for the reader. I can tell you at least one excellent doc will appreciate that. :)

Any place I have ever worked, if it related to quality improvement or risk management, it did not go into the patients chart, that is always a incident report.

You don't understand the risk management and QI process, then. It is not solely brought to bear when there is an "incident." RM and QI are, in fact, ongoing processes that look at all aspects of care and systems, and a great deal of their raw data come from charting. They don't sit in their offices twiddling their thumbs waiting to pounce on an incident report on a lost denture or med error. Someday when you come in for a paycheck or inservice, wander on down to their department and ask them about what they do and what they're working on right now. I'll bet the answers will surprise -- and perhaps gratify-- you.

If you have a good preceptor that teaches you how to do it, you'll be fine. I like to paint a picture of a situation while others tend to leave their documentation pretty bares bones.

There was a discussion here a while back about using "I" in charting such as "I discussed with the patient..." or should you use "writer" or something similar. It was evenly split as I recall.