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Documentation: Getting It Right

Conflicting priorities often derail comprehensive chart entries. (Free for Nurses Week!)

To view the Course Outline and take the test online, click here.

For a printer-friendly version of the exam you can print out, complete and mail in to ADVANCE, click here.

Learning Scope #332
1 contact hour
Expires May 3, 2012

You can earn 1 contact hour of continuing education credit in three ways: 1) For immediate results and certificate; take the test online; grade and certificate are available immediately after taking the test. 2) Mail your completed exam (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the completed exam to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Publications Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 008-0-07), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

The goal of this program is to educate nurses on documentation tools and processes. After reviewing the information, you will be able to:

1. Recognize the pros and cons of differing documentation strategies in use in healthcare.
2. Discuss how to use the electronic medical record as a documentation methodology for support of standard of care.
3. Review your professional documentation and make changes to enhance its effectiveness.

While the process of documentation seems like it should be simple, in reality it is not. Documentation systems are not always user-friendly; documentation tools are not always appropriate or functional. Processes may be inconsistent with changing needs or inflexible. The nurse on the hospital floor, at the nursing home or at patients' homes knows it is essential to document; however, conflicting priorities often do not allow adequate time for meaningful, comprehensive chart entries.

The nursing process is a good place to start when one is assessing documentation practices: assessment, nursing diagnosis, planning, implementation and evaluation. To expect each step of the nursing process for each nursing problem to be documented in the medical record is unrealistic. The nursing process steps are demarcated as individual items, but in reality they are interrelated and interdependent.

The nurse's documentation is augmented and supported by the clinical record entries made by the interdisciplinary team members. This collaborative approach to clinical management emphasizes the skills, knowledge and responsibility of each professional team member, and their documentation rounds out the picture of the patient.

Documentation procedures and tools are diverse and often customized to the needs of the clinical setting.

Narrative Notes

Narrative notes written in the hand of the nurse have been a long-standing practice. Narrative documentation can be illegible, contain non-standard abbreviations, be difficult to interpret and, when not entered with black ink, lead to failure of the record over time.

A blank sheet of paper often brings out the novelist in healthcare professionals. Instead of objective, quantifiable information, the nurse has more of an opportunity to provide extraneous material, which may be interpreted as unprofessional or lead to questions of content. For instance, "BS" may be breath sounds, bowel sounds, blood sugar or bedside.

Flow Sheets

Flow sheets with boxes for documentation are common. Flow sheets with empty boxes may give the appearance of omissions of care and treatment per the example (see Figure).

There often are supplementary narrative documentation forms when flow sheets are used. Discrepancies of events and their timing may be found due to the duplicate entries.

Graphic Sheets

Graphic sheets are most often used for vital signs. This graphic depiction easily demonstrates trends, but, again, omissions are easily visualized when absent.

Vital signs are one of the documentation entries often found in multiple sites in the record. For instance, based on practice, the nurse may document vital signs on the graphic sheet, in the nurse's notes, on a flow sheet and on the medication-administration record. Standardized documentation procedures should be established and monitored. Time is of the essence and documenting the same data element in more than one place is not only inefficient, it can lead to consistency errors.

Charting by Exception

Charting by exception is another approach to documentation. It is a standard in the nursing home setting, where residents are not as acutely ill and not in need of intensive monitoring.

Charting by exception also may be seen in the acute care hospital, where clinical standards of practice define normal findings, and only abnormal findings are entered into the clinical record. There are potential problems with this system due to over- or under-charting by the nurse and interpretation variances from nurse to nurse.

Documentation: Getting It Right

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