Nursing Documentation-if you didn't document it, you didn't do it!

[ChiSmile6]

Ok... so I am sure many of you have heard your instructors or fellow nurses say to document everything you do (education, interventions, therapies, assessments) because if you forget to document, then you pretty much have no proof that you actually did the intervention.

As a new grad I feel like this is something hard for me to wrap my head around. I feel as though I am not sure what exactly to document besides the scheduled tasks on the task list. Do I have to document whenever I talk to a doctor? For example, holding a BP med because the pt's BP is too low, and the MD telling me to hold it. And I guess another question I have concerns progress notes. Is this where I can write all of the important/significant stuff that happened to my Pt. that day? How long on average are these supposed to be? I am having a hard time picking the important things and summarizing them I feel.

A week ago I was working with my preceptor and a K rider infiltrated at the pt's IV site. I said, who do we tell or notify about this? The doctor? Pharm? And she said "no one, what do you mean?" I don't think she even knew that K+ is a med that can cause extravasation.

I guess I feel like I don't quite know yet what is "important" enough to document or notify someone about. I mean I feel like I have a whole body of knowledge and I know to trust my instinct but when I see other nurses going around with no care in the world when I feel like the issue is a big deal, it scares me. I know it's my license and I need to protect it, it just seems like other RNs aren't as paranoid as me.....

help!:anbd:

[stubornone]

When you do let me know, please. I feel the same way. Lost, only time I stop for 12-13 hours is to go to the bathroom a couple times. Stay behind. always. 4-8 or so patients. I am trying, I am 44 and have spent twenty years with the desire to get where I am now, I have only been lic for few months. I will not give up.

[RedhairedNurse, BSN, RN]

so the other day my pt's blood sugar was 96 and the sliding scale said "notify md if lower than 100". Obviously 96 isn't that low, but still, I took the instructions literally. I notified MD and my preceptor said that it was a good idea too. I told one of the other nurses and she kind of laughed at me and said "no one ever does that!"....I feel like I am not getting the hang of this at all!! ahhhh

Are those standard orders or did the physican personally write to notify him of that BS?

That does sound a little odd to me. Maybe the patient has some serious issues with this

sort of thing, you just have to use your best nursing judgement and chart that he was called

and chart any orders that were received. According to the other nurses response, it sounds

like to me that these are orders that show up on everybody and if that is the case, sounds

like something needs to be changed, possibly call your pharmacy or ask your manager why

such standing orders as this exist. At our hospital, we have a certain policy to notify physican

if BS greater than 350, and use hypoglycemic protocol if less than 60.

You will get the hang of it very soon. I've been doing this going on two years and it does

get better.

[jjjoy, LPN]

You gave some very practical advice; thanks! What follows isn't about your specific response here. It's about the advice that newbies hear a lot from different sources:

you just have to use your best nursing judgement.

It is very true and valuable to recognize; however, to my sensibilities, this can come across as disheartening to newbies.

In the future with more experience, the newbie will have more confidence in their judgement and will learn to use it when appropriate. *Until then*, what's a newbie to do? Ask questions, check policy, take extra potentially unnecessary steps just to be safe. For that, in some cases, the newbie may get criticism: warned that they're too slow, exasperated eye rolls, told that something should have been obvious. In other words, there can be an implication that the newbie *should've known* what they are being corrected on and that maybe they just don't have what it takes to be a nurse. And I'm not talking about overtly irresponsible behaviors or serious endangerment of patient safety.

To me, in some cases, to tell a newbie nurse to "just use your best nursing judgement" feels akin to asking a first year piano student to teach themselves to play a concerto and not rely on an instructor or coach to "coddle" them; after all, they know how to play a piano, don't they?

[ChiSmile6]

so if you can't chart "WILL MONITOR...." then what do you write? for example, we do PIEP notes (problem, intervention, evaluation, and plan) I see most nurses write "WILL CONTINUE TO MONITOR..." as the plan. I try to be more specific for example, Plan to offer emotional support regarding new ostomy, assess vital signs, assess pain using numbers system, etc...would this be ok? Should you write your plan in the present tense then? I guess I am a little confused

[Skyfel]

Thanks for that sample charting. I printed the whole thing out and am going to keep it with me at clinicals as examples. Thanks for posting!!!!

[double11]

Nursing documentation can be scary. It's always helpful

to attend a CEU Seminar regarding LAW and Documentation.

One thing that always makes my stomach turn is when i see

someone document "Will continue to monitor" and then doesn't followup.

I.E. 10:47am resident unable to accept any PO meds this day. Will continue to monitor.

No note written by nurse before end of shift (so apparently you monitored nothing).

I continue to see "Will continue to monitor" all the time and i think nurses should get in

the habit of breaking this...

[Orange Tree]

so the other day my pt's blood sugar was 96 and the sliding scale said "notify md if lower than 100". Obviously 96 isn't that low, but still, I took the instructions literally. I notified MD and my preceptor said that it was a good idea too. I told one of the other nurses and she kind of laughed at me and said "no one ever does that!"....I feel like I am not getting the hang of this at all!! ahhhh

We have a sliding scale order set like that, too. I generally ignore it unless it's something I can't get under control with the orders that I already have. And there is another one for potassium that says to call MD if K+ is less than ____ (I forget the value). The same order set covers K+ replacement and reassessment, so it seems kind of pointless to call.