Documentation, not only communicates to other healthcare providers but it also paints a picture of the patient in ways that an assessment lacks. The nursing school puts emphasis on this, at least in my program, the clinical paperwork that was turned in weekly gave students a patient to practice assessments, administering medications, and perform some interventions. The weekly care plans, assessments, and nursing notes aid in the viewing the patient as a whole person not just a diagnosis.
#1 Know your requirements
Every unit is different and will require a different amount of documentation, for example on the medical-surgical unit we are only required to write a minimum of three notes for the six patient during the shift, whereas on a progressive care unit or a step-down unit with four patients a note is expected every 2-hours. The amount of documentation and notation will depend on the acuity and the severity of the patient. The notes and amount of documentation will differentiate between units. If you are new to a unit or floating from a different unit ask a supervisor or another nurse.
#2 “If it wasn’t documented, it wasn’t done.”
In the eyes of doctors, nurses, lawyers, if something was not documented it was not done. If a patient has a change in behavior or vitals, note what was observed, the intervention that was done, and the outcome or statement by the patient. If nothing at all is documented, then it will be assumed that nothing at all was done. If something happens to the patient down the line and the case is looked at by hospital or the court, the medication, vital signs, and notes will paint a timeline. If education is done with a patient regarding medication, or disease process, such as diabetes. The topic, teaching style, and response or acknowledgment of the patient are essential to note and document either through care plans or notes.
#3 Keep the documentation bias-free
Notes should only include what is seen or statements from the patient. A good example, if you walk into a patient’s room and the patient is on the floor. Unless you witness the patient falling to the floor, or placing them-self onto the floor. In an event like this stick to what you saw don’t elaborate or draw conclusions. If the patient tells you any details, place them in parenthesis and include “patient stated” or “stated by a patient.” Remember to only document or note what you witness and saw.
#4 Jargon and voice
The hardest thing about writing a note correctly for me was the jargon. The way to present a thought or intervention that sounds professional. I would read other nurse’s notes to see how they performed scenarios and events. Until I gain my own footing in the note writing, I purchased a book to help with the details. Nursing Notes the easy way: 100+ Common Nursing Documentation and Communication Templates by Karen Stuart Gelety. This pocket-sized book lists opening notes, discharging a patient, starting an IV, changing an IV, to a patient with confusion. This little book gives an easy template to writing notes, in a non-bias voice with the needed information. Unable to find the right words and missing data was a worry I had my first few months as a new nurse. Some other books are available the one listed was just the one that I actually used and still keep in my bag. Eventually, the language becomes second nature, but there are times I reference my book for a rare procedure or a new one.