12 Nurse-Tested Tips for Effective and Efficient Documentation

This article was republished with permission from SCRUBS Magazine.

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Nurses, it’s time to talk about documenting. We know what you’re thinking: Documentation is a four-letter word when you’re a busy nurse. If you’re more eager to deal with a patient’s C. diff flare-up than do your charting, it may be time to try making documentation a little easier.

That’s why we asked the nurses on our Facebook page to tell us their best advice to keep in mind for accurate and efficient documentation.

“Just the facts. No judgments, opinions or blame. Correct timeline, making sure each physician call is documented: when, why, outcome, orders and results of orders. NO BLOCK CHARTING!” —Denise A.

“Document when you do it. Don’t wait until the shift is over.”

—Paula V.

 

“Find out what the minimum documentation standard is in your institution. Document those things and other exceptions, then care for your patients, not the chart.” —Jerry B.

“Say no to ‘cookie cut’ charting, and for God’s sake, use spell check.” —Regenia J.

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“Write as you go. Less chance of forgetting something. If it’s not written, it’s not done.” —Tash O.

“Always good to chart in real time… But let’s be serious, who has TIME for that? If I have had the same patients before… I chart in the room what is different from last night’s assessment right then so I don’t forget. If I need to move on right away, I write down the time and jot a note on my paper sheets from my pocket and move on.” —Stephanie B.

“Chart the truth! My parents both have recently spent time in the hospital. A night-shift nurse charted she had a good night. She had a horrible night and was denied a medication that would have helped.” —Rhonda C.

“Always chart safety precautions… Like safety rails up, call light in reach, go bag near patient, etc.”—Sherry W.

“No abbreviations. Use the exact time. Lawyers look at those and despite commonly used abbreviations can twist their meanings around.” —Lizzie B.

“Chart facts, not opinion. Avoid late entries.”

—Andrea H.
“Proofread…ask questions from other nurses before finalizing notes!” —Pamela J.

Ask yourself if the person going through the chart would be able to put all the puzzle pieces together. Times matter and details matter.” —Mitzi H.

What tips for documenting would you add to this list? Drop your advice in a comment below.

 


This article was republished with permission from SCRUBS Magazine.

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2 COMMENTS

  1. Use a format consistently, whatever it is. I use a systems approach – cardiac, respiratory, renal, GI, Neuro, MS/I, social, psych. Details fall in place.

  2. Anytime you receive a patient, be sure to have 2 RN’s in person for the handoff. The receiving nurse should always document the condition of the patient on arrival, and the exiting nurse should also document the state in which she handed the ptient over. This is a JC safety standard and is so important, for all three parties.

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