Nursing Supervisor

Short pointers on documentation.

Remember when you document act like you are painting a picture. When a person read your note they should be able to visualize what the patient look like.

Then you want to start from head to toe, if you are in a nursing home it is not as technical you do not have to document every two hours.

In a nursing home you should be charting why is the patient on the report, example: patient continues on Cipro 500 mg day 2/10 for UTI, no adverse reactions, voiding without any C/O discomfort, urine dark amber in color no foul smell.

After you state why you must state the out come.

If the patient states he or she has pain address the issue, C/O pain level 3/10 Tylenol given at 6 pm with relief.

Head to toe--Start off with their orientation status, make sure to mention what the patient did on your shift, give yourself credit for any patient teaching that you did. Often nurse drop the ball with this we are pressed for time, we don't take the credit for the excellent job that we do.