Documentation Refresher

The objective of this module is to refresh the documentation skills you have in order to improve documentation on the units. 

Documentation is an integral part of the nursing process, as it communicates patient status, nursing assessments, and nursing care provided. Based on documentation, a reader should be able to paint a reasonable picture of a patient.

Documentation on both units is currently not meeting expectations of quality patient care or nursing standards (see CRNBC for standard). Some of the issues noted include:

Complete the Self-Assessment that follows to assist in identifying areas that may need refreshing. 

Self-Assessment

The Modified Early Warning Score (MEWS) needs to be completed with the patient's vital signs at the beginning of each shift and then prn.

  • True
  • False

If a section on the 24 HR flowsheet does not apply to the patient it is okay to indicate "N/A" in that section.

  • True
  • False

A patient is given a medication in error by the nurse. The nurse documents in the patient chart, "Patient given 25mg digoxin in error. Dr aware. Pt stable. Incident report completed." This is correct documentation for an incident like this?

  • True
  • False

A patient has a fall on the unit. Which is the best example of charting by exception for this situation?

  • 1310 D: pt found on floor beside bed. A: Returned to bed. Dr. Notified. RN
  • 1310 D: pt found sitting on the floor beside bed. VS stable. Denies any injuries. A: pt assisted into bed. Dr. Smith notified. Will monitor. PSLS completed and family informed. RN
  • 1310 D: pt found sitting on floor beside bed. Head to toe assessment completed. Pt states she "slipped when getting up". Denies any injuries. A: pt able to get into bed with assistance. Call bell placed within reach and pt instructed to call for assistance when getting up. Dr. Smith notified. No new orders received. Pt's daughter Kim notified of fall. Will monitor. 1430 R: Pt VS remain similar to baseline. Denies pain or discomfort at this time. RN
  • 1310 D: pt found sitting on floor beside bed wearing patient gown. Roommate says the patient "must have fallen when she was going to the bathroom". Pt states she "slipped when getting up". Denies any injuries. A: pt able to get into bed with assistance of writer and Steve, the full time PCA. Call bell placed within reach and pt instructed to call for assistance when getting up. Dr. Smith notified and stated, "that's unfortunate". No new orders received, though the writer thinks an xray is needed. Pt's daughter Kim is called on her cell phone and notified of the fall. Will monitor. 1430 R: Pt VS remain similar to baseline each time writer takes them. Pt denies any pain or discomfort and refused the Tylenol writer thinks she should take. RN

What does the DAR charting format refer to?

  • Data, Assessment, Reason
  • Data, Action, Response
  • Data, Assessment, Response
  • Document, Action, Response

When documenting medication administration, it is necessary to document in the nurses' notes, as well as the MAR, the med dose given, what time the med was given, and the route it was given.

  • True
  • False

Beth and David complete a complex dressing change on a patient. Beth notices David documented incorrectly about the wound. To help David, Beth crosses out the error and corrects it for him. When she tells David what she has done he becomes angry. Why?

  • David is embarrassed that he made an error
  • It is illegal to alter another nurse's documentation
  • David thinks Beth is wrong in her assessment, not him
  • Beth is a busy body who can't keep her nose out of his business

The nurse assesses her patient and finds him to be oriented to person, place and time with no evidence of delirium. When she goes to document, she notices the delirium screen has not been completed by Nora on nights. What action should the nurse take?

  • Nothing. The patient is not delirious so the delirium screen is not required.
  • Complete the delirium screen and tell the CNL that Nora is lazy.
  • Ask her colleagues if they know whether Nora has problems at home because it is affecting her work.
  • Complete the delirium screen; talk to Nora to determine why it was not completed.

What is the purpose of nursing documentation?

  • To evaluate quality of care provided
  • It is a professional standard of care
  • To provide evidence in case of legal actions
  • To reflect nursing care provided and the patient's response

Choose all the words  and phrases that are appropriate to use when documenting.

  • Slept well
  • Normal
  • Accidentally
  • Decreased air entry to lung fields
  • Smiling
  • Severe
  • Appears sad
  • Moaning
  • Tolerated well
  • Reddened
  • Abdomen rigid
  • Pain 2/10
  • Voiding QS
  • Breath sounds normal
  • Large amount
  • Patient sleeping
  • Increased BP
  • Malodorous
  • Swollen
  • Occasional

Documentation Basics

Documentation Basics


Documentation Basics

If you didn't document it, it wasn't done. If it wasn't done, you are negligent.

  • Documentation describes what you observed, what you did, and includes the following:
  • Status of the patient; changes in status,
  • Care given; communications with physicians,
  • Documentation that physician's orders have been followed,
  • Documentation that policies and procedures have been followed


Documentation should provide a clear picture of:

  • Needs or goals of the patient
  • Nurse’s actions based on the needs assessment
  • Outcomes and evaluation of those actions

Characteristics of Quality Documentation 

Objective: Avoid charting what someone else may have told you. Only document what you see, hear and feel. If you chart something the patient reports, be sure to indicate the patient is stating it, such as “patient stated he was not in any pain.”

Legible: Legibility is the biggest problem with documentation. Make sure your handwriting is legible. Your documentation must be legible to anyone who may read it. If you know you have poor penmanship, begin to print. 

Accurate: Accuracy is one of the most important factors when it comes to charting. Even if you did the procedure correctly or gave the right dosage of medication, if you charted it incorrectly, it appears you did it wrong.

Timely: You may not always be able to, but try to chart as soon as possible after doing something. If you do have a late charting entry, follow hospital policies.

"But that's what I meant!"

You can most likely think of inappropriate terms used in documentation.  “Tolerated procedure well” is a meaningless statement, as it does not give any indication that a patient assessment was done. “Patient’s condition satisfactory” is also a meaningless statement, as there is no indication that an assessment was done and the term "satisfactory" means different things to different people. 


You need to have accurate assessment data. The following phrases are more accurate and demonstrate that an assessment has occurred: 

  • “Awake and resting in bed. No complaints of pain.”
  • “Awake and resting in bed. States "I have no pain”
  • “Responding and recovering according to standards for procedure”.  


The following words or terms are generally inaccurate and should be avoided:

  • Good, poor, bad unless said specifically by the patient “I had a poor sleep”
  • Small, medium, large – be specific with measurements if possible
  • Seems, appears, apparently - document what you see, hear, smell
  • Could be, may be
  • Miscalculated, accidentally, unintentionally, mistake, error - these are for the incident report and not part of documentation
  • Somehow
  • A little, a lot
  • Severe, intense, mild, moderate
  • Stable
  • Normal

The Do's That Make Charting Easier


Below are some guidelines to assist with your documentation.

  • Check  that you have the correct chart before you begin writing
  • Do describe everything exactly as found by inspection, palpation, percussion, or auscultation.  Chart your normal findings if using narrative charting.
  • Chart subjective data from the patient by directly quoting it (“...")
  • Make sure your documentation reflects the nursing process and your professional capabilities
  • Write legibly. Illegible handwriting is one of the most common deficiencies in documentation
  • Do chart the patient's response to a  medication when given as an intervention e.g. Tylenol for pain, gravol for nausea


  • Do chart precautions or preventive measures used, such as bed alarm
  • Record each phone call to a physician, including the physician’s name, exact time,  message, and response
  • Chart a patient's refusal to allow a treatment or take a medication.
  • Chart patient care at the time you provide it. If you remember an important point after you've completed your documentation, chart the information with a notation that it's a "late entry." Include the date and time of the late entry
  • Document often enough to tell the whole story
  • Use approved abbreviations, correct spelling, grammar and terminology contribute to accuracy in your documentation


Here is an example of both incorrect and correct nursing documentation: 

Incorrect Way:

Communicated with patient's family to discuss his condition. Patient may go for an angiogram.

Correct Way: 

I contacted Mr. Boondoggle's wife at 1415 hours. I explained that his cardiac status was worsening and that he was being prepared for a cardiac catheterization procedure scheduled for 1600 hours. 

The Don't of Charting


Here are a few guidelines to assist with ensuring you document clear, concise, and relevant information.


  • Don’t write a novel. Be clear and concise including only relevant information
  • Don't chart a symptom, such as "c/o pain," without charting what you did about it
  • Don’t use vague terms such as “normal,” “abnormal,” “good,” or “poor”, “satisfactory”.  Be specific – e.g.. “accessory muscle use noted during respiration” as opposed to “resps satisfactory”
  • Don’t confuse incident reports (PSLS) with patients’ charts. This is a very complicated area. The rationale is that what goes to quality review may be highly critical of how an incident transpired, but it is confidential and stays with quality review. Events that occurred and actions taken should be documented in patient chart. e.g. “Patient received extra dose of Metoprolol 25 mg at 0900. Dr. Smith phoned and notified. BP and HR to be monitored Q1H x 4.”
  • Don't blame or accuse other healthcare providers in documentation, "because RN Stella forgot to give the med".


  • Don’t chart “I left a message” or “MD paged”. Avoid general statements. Beware of general statements that can be misconstrued. For example, you wrote “MD called.” Did you mean:
    • You called and are waiting for a return phone call?
    • The physician called the nurse?
    • The nurse called and spoke to physician?
  • Nurses have a duty to advocate for the patient. If you do not hear from the doctor, you have to call back, or call another doctor or ask your CNL what to do.
  • Don’t use non-approved abbreviations or symbols in your documentation as they can easily be misinterpreted. The following should be avoided :  <, >, up and down arrows
  • Don’t make judgments or give opinions when documenting (e.g. “patient appears sad”)


When you complete a PSLS (incident report), this should be documented in the nursing or ID notes.

  • True
  • False

What is the most common deficiency in documentation?

  • Legibility
  • Timeliness
  • Use of unapproved abbreviations
  • Overcharting

Let's try this again. Choose the words and phrases that are appropriate to use when documenting.

  • Slept well
  • Normal
  • Accidentally
  • Decreased a/e
  • Smiling
  • Severe
  • Appears sad
  • Moaning
  • Tolerated well
  • Reddened
  • Abdomen rigid
  • Pain 2/10
  • Voiding QS
  • Breath sounds normal
  • Large amount
  • Patient sleeping
  • Increased BP
  • Foul odour
  • Swollen
  • Occasional

24-HR Patient Care Flowsheet (5AB)

Charting By Exception


Charting by exception (CBE) is a documentation system that states only significant findings or exceptions to normal findings.

 Since the CBE system has so much subjectivity, clear guidelines for “normal” are included under each system.  If there are abnormal findings, the nurse is required to explain these findings in the nursing notes. Recording an asterisk means that a narrative nurse’s note has been charted to explain why the standard was not met.

It is prudent on the nurse’s part to place an “N/A” (not applicable) to areas of a form that do not apply to a particular patient’s care, instead of leaving blank spaces, as this indicates that the system was assessed.

Regardless of the system of charting, use the nursing process as a guideline when charting. The nursing process includes the following four processes of nursing care:

  • Assessment – objective and subjective data
  • Planning – developing a plan of care
  • Implementation – specific actions taken by the nurse
  • Evaluation – determining whether the plan of care was effective

24-Hour Patient Care Flowsheet (5AB)


The 24-Hour Patient Care Flowsheet (5AB) is used for patients who are not on a pathway (Cardiac Surgery Pathway).

Patient label and date are required on both pages of the form. The assessment sections contain “normal” findings for a patient. If your patient meets this stated criteria a check  is all that is required. If the patient deviates from any of the stated criteria, a variance should be documented and elaborated upon. 

When documenting about a variance the Data Action Response, or similar format, is to be used.

Example

0700  Heart rate increased at 112 bpm. Patient denies SOB, chest pain. Skin warm and dry. Dr. Sam informed of patient status at 0730. Order received to give scheduled beta blocker STAT.RN

0720 Scheduled beta blocker given at 0715. Will reassess heart rate in one hour. RN

0915  Heart rate at 88 bpm. Will continue to monitor. RN

DAR Charting

Data: Subjective and/or objective information that supports the assessment

Action: Completed or planned nursing interventions based on the nurse’s assessment

Response: Description of the impact of the interventions on client outcomes.

A Closer Look at the 24 Hr Flowsheet

Vital Signs/MEWS: Completed as per protocol – beginning of every shift, change in status, prn. MEWS must be completed with every set of VS, not just at the beginning of the shift. MEWS is effective at highlighting patient deterioration because it demonstrates a trend. A trend cannot be seen if the MEWS is not completed with every set of VS.

Vascular/Orthopedic: Completed with baseline patient assessment each shift and prn

Central Nervous System: Completed with baseline patient assessment each shift and prn

Pain: Document presence and location of non-cardiac pain using pain scale of 0 to 10, or other pain indicator. If a patient is pain free there is no need to document that. If a pain complains of pain the Pain SBAR requires completion. If a patient is on a 24 hr pain management flowsheet make sure to note that on the 24 hr flowsheet in the indicated space.

Neurological: The Delirium Screening and Care Plan (PHC-NF351) must be completed on all patients each shift. Risk Factors must be indicated, the screen signed and dated, timed.

Each line of the CAM screening must indicate ‘+’ or ‘-‘. A line from the top of the column to the bottom is not acceptable. If a patient is CAM positive, PRISME interventions must be indicated.

Respiratory: Respiratory rate is to be counted for a full minute to determine an accurate rate, as respiratory rate is an important indicator in patient deterioration (MEWS).

Cardiovascular: Indicate whether patient is on telemetry by checking the ECG strip flowsheet box. There is no need to document findings that meet the criteria indicated, only variances. Variances are to use the DAR format.

Gastrointestinal: Diet type and last bowel movement are to be documented where indicated.

Genitourinary: If patient has a urinary catheter in situ this needs to be indicated, as well as the reason for the catheter.

Integumentary: Indicate specialty surface if one is used. Braden scale is completed q48 hr, therefore check Braden tool to see if reassessment is required and complete if needed.

Musculoskeletal: Activity level refers to the ordered activity i.e. AAT, bedrest. If a patient is on bedrest indicate the frequency of turning where indicated. Hygiene refers to the type of activity undertaken (sponge bath, shower) and not the amount of assistance required. Baseline criteria is patient is independent with these activities. Document a variance if the patient requires assistance and how much.

Psychosocial: Document any variances from baseline.

Safety: Assess safety and document only if all aspects are met. If something in the safety check is missing, rectify and document.

Dressings/Incisions: Applies to any wounds or incisions the patient has. If does not include central line dressings which are documented on page 4. Indicate site of the wound(s). If the wound/incision is uncomplicated documenting on the 24-Hr flowsheet is appropriate, however, if the wound/incision is complex, complete the Wound Assessment/Documentation Flowsheet (PHC-NF099). Refer to this additional flowsheet when documenting.

Example

0930 ­ Refer to Wound Assessment flowsheet RN

Drainage Tubes: Document site as well as any additional flowsheets associated with tube (Chest tube flowsheet). Indicate location of tube(s). If no drainage tubes present document ‘n/a’.

Patient Teaching: Patient/family teaching happens every day; therefore this section should not be left blank. Indicate what was taught and to whom, any teaching materials given and patient/family’s level of understanding, or lack of understanding.

Other: Document any tests, admissions, discharges, or other items that do not fit into the other categories here.

Fluid Balance: Indicate amount of fluid restriction if applicable. If fluid balance is ordered any fluids that go into or out of the patient require documentation. Intake includes IV fluids/meds, PO fluids, parenteral fluids. Output includes, urine, emesis, blood, chest tube volumes, drain volumes. The 24 Hr fluid balance is to be calculated at 0600 each day.

If a patient is recording their own ins and outs it can be noted on the fluid balance to refer to this sheet for details.

IV/CVC Assessments and Procedures: Any assessments and interventions involving IV access are documented here. The Legend for documenting in this section is located at the bottom of the form.

If your patient is alert and oriented to person, place and time, you need to write this under the Neurological section of the 24HR flowsheet.

  • True
  • False

The 'Patient Teaching' section of the 24 HR flowsheet should not be left blank.

  • True
  • False.

Cardiac Surgery Documentation

Cardiac Surgery Documentation (not transplant or VAD)



The cardiac surgery documentation consists of three separate documents, the clinical record, the 24 hour documentation flowsheet, and the clinical pathway.

1.     Clinical Record

Vital Signs/MEWS: Completed as per protocol – beginning of every shift, change in status, prn. MEWS must be completed with every set of VS, not just at the beginning of the shift. MEWS is effective at highlighting patient deterioration because it demonstrates a trend. A trend cannot be seen if the MEWS is not completed with every set of VS.

Vascular/Orthopedic: Completed with baseline patient assessment each shift and prn

Central Nervous System: Completed with baseline patient assessment each shift and prn

Pain: Document presence and location of non-cardiac pain using pain scale of 0 to 10, or other pain indicator. If a patient is pain free there is no need to document that. If a pain complains of pain the Pain SBAR requires completion. If a patient is on a 24 hr pain management flowsheet make sure to note that on the 24 hr flowsheet in the indicated space.

2.     24 Hour Documentation Flowsheet

Assessments are documented based on systems by checking the appropriate box. The flowsheet lists expected assessment finding data. Documenting  on the form allows one to record assessment findings but not interventions or evaluation; these need to be documented on the Clinical Pathway document using the DAR approach.

 

3.     Clinical Pathway Flowsheet

The Clinical Pathway is used to assess a patient’s progress towards specific outcomes as outlined on the form. Complete this form near the end of the shift to allow the patient to achieve the outcome, unless a variance is noted earlier (see above).

Example: 

24 hr flowsheet:  CVS  R Edema: +2 non-pitting to bilateral lower legs Pt 1.6 kg above target weight. Will give diuretic as ordered. RN.

1030 Patient diuresed 1200 cc clear amber urine. Will monitor. RN

Clinical Pathway:  Cardiovascular System – place asterisk beside outcome then document under Progress Notes on back of form or state “refer to nursing notes” if already documented. 

The Clinical Pathway should be completed as soon as possible in your shift.

  • True
  • False

If I have documented on the 24Hr Assessment flowsheet about a variance, I can write on the Clinical Pathway "refer to nursing notes" instead of writing it again.

  • True
  • False

Interdisciplinary/Progress Notes

Interdisciplinary Notes


The Interdisciplinary (ID) notes are used to communicate patient information between health care providers (physicians, NPs, nurses, allied health, social workers, etc).

The expectation is that each RN write an ID note for each of their patients at the end of shift that communicates the status of the patient and/or any non-urgent outstanding problems or issues that have not been addressed. If issues are urgent then the MRP/NP should be phoned and not left an ID note.

ID notes are not just for communicating adverse patient outcomes. If a patient is progressing along a pathway or tolerating the desired course of treatment, this needs to be communicated.

Avoid vague words (satisfactorily, good, stable) when writing your note and keep it brief and relevant. Do not write a complete head to toe assessment here either, as this is double charting and a waste of time. Writing “refer to nursing notes for details” can guide the reader to further information.

Unacceptable Note:

Sept 1/16, 0630, Nursing

Patient stable for most of shift. Dr called this morning for patient complaints of pain. Hydromorphone ordered and effective at relieving pain. RN

  • Stable -  based on what?
  • Most of shift - vague and meaningless
  • Dr. called this morning - which doctor and at what time?
  • Pain - what kind of pain?
  • This whole note about the pain is unnecessary as the pain has already been dealt with. Nothing that isn’t already known or documented is being communicated. 

Acceptable Note:

Sept 1/16, 0630, Nursing

Patient progressing according to Cardiac Surgery Pathway. VS remains within stated parameters. Pt complaining of constipation and current meds not working. Last BM three days ago.  Patient would like to use his own herbal remedy. Please assess.RN

This note includes pt status and a specific non-urgent problem that needs addressing.  

If there are no changes to my patient's condition an ID note is not needed.

  • True
  • False

Check Your Understanding

A patient is given a medication in error by the nurse. The nurse documents in the patient chart, "Patient given 25mg digoxin in error. Dr aware. Pt stable. Incident report completed." This is correct documentation for an incident like this?

  • True
  • False

The Modified Early Warning Score (MEWS) needs to be completed with the patient's vital signs at the beginning of each shift and then prn.

  • True
  • False

If a section on the 24 HR flowsheet does not apply to the patient it is okay to indicate "N/A" in that section.

  • True
  • False

What are three purposes of nursing documentation?

  • Communicate patients’ progress to other health care providers
  • It is a professional standard of nursing
  • Reflects nursing care provided and the patient's response
  • Monitor a patient's progress
  • To provide evidence in case of legal actions
  • Demonstrate adherence to accreditation standards

A patient has a fall on the unit. Which is the best example of charting by exception for this situation?

  • 1310 D: pt found on floor beside bed. A: Returned to bed. Dr. Notified. RN
  • 1310 D: pt found sitting on the floor beside bed. VS stable. Denies any injuries. A: pt assisted into bed. Dr. Smith notified. Will monitor. PSLS completed and family informed. RN
  • 1310 D: pt found sitting on floor beside bed. Head to toe assessment completed. Pt states she "slipped when getting up". Denies any injuries. A: pt able to get into bed with assistance. Call bell placed within reach and pt instructed to call for assistance when getting up. Dr. Smith notified. No new orders received. Pt's daughter Kim notified of fall. Will monitor. 1430 R: Pt VS remain similar to baseline. Denies pain or discomfort at this time. RN
  • 1310 D: pt found sitting on floor beside bed wearing patient gown. Roommate says the patient "must have fallen when she was going to the bathroom". Pt states she "slipped when getting up". Denies any injuries. A: pt able to get into bed with assistance of writer and Steve, the full time PCA. Call bell placed within reach and pt instructed to call for assistance when getting up. Dr. Smith notified and stated, "that's unfortunate". No new orders received, though the writer thinks an xray is needed. Pt's daughter Kim is called on her cell phone and notified of the fall. Will monitor. 1430 R: Pt VS remain similar to baseline each time writer takes them. Pt denies any pain or discomfort and refused the Tylenol writer thinks she should take. RN

What does the DAR charting format refer to?

  • Data, Assessment, Reason
  • Data, Action, Response
  • Data, Assessment, Response
  • Document, Action, Response

When documenting medication administration, it is necessary to document in the nurses' notes, as well as the MAR, the med dose given, what time the med was given, and the route it was given.

  • True
  • False

The nurse assesses her patient and finds him to be oriented to person, place and time with no evidence of delirium. When she goes to document, she notices the delirium screen has not been completed. What three actions should the nurse take?

  • Nothing. The patient is not delirious so the delirium screen is not required.
  • Complete the screen and document her current CAM assessment on the delirium screen.
  • Talk to the Nora, the nurse from the previous shift, to determine why the screen was not completed.
  • Review the delirium protocol to verify her understanding of the protocol.
  • Tell the CNL that Nora is lazy.
  • Ask her colleagues if they know whether Nora has problems at home because it is affecting her work.

Beth and David complete a complex dressing change on a patient. Beth notices David documented incorrectly about the wound. To help David, Beth crosses out the error and corrects it for him. When she tells David what she has done he becomes angry. Why?

  • David is embarrassed that he made an error.
  • It is illegal to alter another nurse's documentation
  • David thinks Beth is wrong in her assessment, not him.
  • Beth is a busy body who can't keep your nose out of his business.

Choose the words or phrases that are appropriate to use when documenting.

  • Stable
  • Moaning
  • Seems like
  • Auscultated
  • Mumbling
  • Soft BP
  • Severe
  • Pt said, "Slept well"
  • Reddened
  • Crying
  • Depressed
  • Normal
  • PSLS was completed
  • Pain 6/10
  • Moderate amount
  • Satisfactory
  • +2 edema
  • MD aware

Summary

Summary

You have completed the module. 

Over the next several months audits will be conducted to monitor the state of nursing documentation. We encourage you to follow up with your colleagues if you notice any documentation that does not meet the standards set for our units.


Audits will be conducted over the next little while to monitor documentation. Huddles will be held over the next several months focusing on documentation. Please try to attend.