Nursing Skills

Five Tips for Improving Your Nursing Documentation

Nursing SkillsNovember 11, 2016

Documentation is everything. This has always been true in medicine, especially among nurses. Learning to document—thoroughly, accurately and consistently—is crucial for both proper patient care, and for the preservation of your career.

The latter is true because documentation proves that you have followed guidelines and administered medications and treatments correctly, in the correct dosages, and at the proper times. Failing to chart your activities can affect your patient’s care and could undermine your professional credibility. If anything goes awry, you can be sure your actions leading up to the incident will be reviewed carefully. By carefully and faithfully charting everything you do, you insulate yourself from any accusations of fault. Be aware of the golden rule, “if it’s not documented, it’s considered not done”. 

Certain times and circumstances are especially crucial when it comes to thorough, timely documentation. 

The busier you are, the more important it is to document.

When you’re busiest is when omissions and errors are more likely to occur. Unfortunately, it’s also the time when careful documentation of your actions, and the status of your patients, is most crucial. Avoid dropping the ball during these critical times:

When receiving verbal orders
During codes
During shift changes
During patient transfers
While verifying medication orders
When you’ve received critical values from the laboratory.

Critical values should be reported to a nurse (you) within 15 minutes of the time they are verified by the issuing lab or diagnostic service. You, in turn, should report these if appropriate. If he or she cannot be contacted within a half hour, follow the fail-safe plan instituted by your facility.

Take care when writing text to explain an abnormal finding.

If your institution uses the nursing charting by exception method, which requires you to use check marks to indicate when parameters fall within defined “normal ranges” (also known as “within defined limits” (WDL)), you should memorize these limits and carefully explain any “abnormal” finding. 

Always note (and highlight) any allergies and note special waivers.

Some patients refuse blood and all blood products, for example. Failure to follow these expressed wishes and notification of the doctor could expose you and your institution to legal liability. Failure to note an existing allergy could have dire consequences for the patient’s health.

Never chart in advance.

If it hasn’t happened yet, it’s not chartable. Enough said.

Use caution and good judgment when charting “frequent flyers”.

Nurses are only human. It’s understandable that repeat patients, who tend to clog the healthcare system with continual complaints, might occasionally be viewed with a modicum of exasperation. Nevertheless, each and every patient deserves your full attention and appropriate medical care. When charting any encounter with such patients, avoid implicating yourself in any substandard application of care. Eventually, one of these patients could present with an actual, life-threatening issue. Be sure you play no role in dismissing his or her concerns. 

Always look into any new pain complaints.

Pain is the body’s way of indicating that something’s amiss. While some patients make your job more difficult by tending to complain constantly, any new pain complaint should be investigated and documented. 

Legal proceedings generally can occur up to two years after an incident, due to local statutes of limitation. Ironclad charting is your best defense. 

Should you be involved in a medical malpractice lawsuit, you may be summoned to testify, often long after the fact. Obviously, careful charting of any and all professional actions taken—or not taken—by you during the relevant incident will be of paramount importance. Good charting will serve as your best defense against any criticism of your actions, or lack thereof.

Consider purchasing professional liability insurance to go that extra step in protecting yourself.