What Should Be Included In Nursing Documentation?

Nursing Documentation

Nurses work demanding shifts and managing documentation can be a phenomenal task. Keeping accurate and timely nursing records is essential for communication among all members of the patient’s healthcare team and to support the delivery of safe, appropriate and continuous care. Good records allow healthcare providers to identify problems and the action taken to correct them. Nursing transcription is a viable strategy to ensure accurate and timely electronic health record (EHR) documentation. For clear, concise and comprehensive patient charts, nursing documentation should include all the essential components with regards to professional nursing standards.

Guidelines for Nursing Documentation

The American Nursing Association (ANA) has set down primary guidelines that serve as the gold standard for the basis of nursing documentation. The ANA defines high-quality nursing documentation as inclusive of the following characteristics: “Accessible, accurate, relevant, consistent, auditable, clear, concise, complete, legible/readable, thoughtful, timely, contemporaneous, sequential, reflective of the nursing process, and retrievable on a permanent basis in a nursing-specific manner.” The ANA further states that all entries in the medical record must be legible/readable and that standardized terminology should be used to describe the planning, delivery, and evaluation of nursing care.

Essential Elements of Nursing Documentation

Nurses are usually responsible for creating the patient chart and updating all information from vital signs to the patient’s pain level and other parameters, and any progression of symptoms or emergencies the patient experienced during the hospital stay.

The patient’s EHR should have the information necessary to support informed decision making and high quality care by the care team. Timely documentation of the following aspects regarding the patient should be maintained in the medical record:

  • Evaluations
  • Clinical problems
  • Communication with other healthcare providers
  • Communication with and education of the patient, family, the individual designated as the patient’s caregiver and other third parties
  • Medication records
  • Order acknowledgement, implementation, and management
  • Clinical parameters
  • Responses and outcomes, including changes in health status
  • Plans of care that take the patient’s social and cultural needs into account

Writing The Nursing Note

Nurses generally follow the S.O.A.P. (Subjective, Objective, Assessment, and Plan) format when writing progress reports.

  • Subjective: The date and time, the patient’s name, the names of the doctor and nurse, general description of the patient and reason for the visit is documented. The subjective section includes information gathered from the patient or family members/caregiver about the reason for the visit, the patient’s health, and symptoms the patient is experiencing such as pain.
  • Objective: Objective information to include in the note includes vital signs – body temperature, pulse rate, respiration rate, and blood pressure, evident symptoms and results of laboratory tests ordered by the physician. By supporting the subjective data, objective information helps the physician with diagnosis.
  • Assessment: This section of the nursing note includes information about the patient’s condition based on the assessments done. It should list medications prescribed, the response to them, and any changes are noticed in the patient’s condition after admission.
  • Interventions and Care Plan: This section records details about the care the patient received during the nurse’s shift. Information can be provided about the times medication were administered, requests made by the patient, and additional observations made about the patient’s condition. The care plan section of the nursing progress note should include any intervention planned for the benefit of the patient.

A paper published in Community Eye Health advises nurses that if they have any doubt about what to include in the note, they should ask themselves the following: “If I was unable to give a verbal handover to the next nursing team, or the next shift, what would they need to know in order to continue to care for my patients?” The goal should be to ensure that patient’s care is not affected by the change of nursing shift.

Tips for Keeping Good Nursing Records

  • Ensure clear, legible records
  • Record all relevant observations in the patient’s nursing record, as well as on any charts throughout the day so that important details on the patient’s status are not left out.
  • Sign each entry, giving your full name and aim to record the exact time of the patient visit,
  • Include medications given, dosage, the time they were administered, and reactions of the patient to the medications
  • Clearly state the diagnosis as well as any problems the patient is experiencing (like pain), and treatment administered
  • Make notes of all allergies, including allergies to medications
  • Document physician consultations, including time, remarks, patients response and actions prescribed
  • Note all pertinent observations in the patient’s nursing record, as well as on any chart
  • For hand-written notes, consider using only blue or black ink. If you make a mistake, cross it out using a single line and sign it.
  • For a patient scheduled for surgery, make sure to include the consent form for the operations signed clearly by the patient in the record. Also create a nursing checklist to ensure that the patient is prepared for the scheduled surgery.
  • Record all discharge plans
  • Maintain HIPAA compliance and protect the patient’s confidential information.
  • Document the patient’s wishes
  • Avoid jargon, meaningless phrases, or personal opinions
  • Use only familiar and commonly understood abbreviations (for example, BP for blood pressure, DM for diabetes mellitus, VA for visual acuity)
  • All statements should be factual and recorded in the order they happen. Don’t not speculate, make offensive statements, or joke about the patient

Accuracy in nursing documentation is crucial since physicians, nurses and other healthcare providers depend on the patient’s chart to provide care. Outsourcing nursing transcription to an experienced medical transcription company is a practical way to ensure accurate, timely, and detailed documentation that provides evidence of the level and quality of the nursing care provided.

Julie Clements

About Julie Clements

Joined the MOS team in March of 2008. Julie Clements has background in the healthcare staffing arena; as well as 6 years as Director of Sales and Marketing at a 4 star resort. Julie was instrumental in the creation of the medical record review division (and new web site); and has especially grown this division along with data conversion of all kinds.