Learning Objectives
By the end of this section, you will be able to:
- Identify how to document data collected during the implementation phase
- Describe requirements for documentation of risk management
- Define how to document evaluation of interventions
- Describe the importance of accuracy when documenting
- Identify appropriate terminology to use when documenting
- Recognize types of source-oriented documentation
- Describe different problem-oriented types of documentation
Nurses document a wide range of data—including vital signs, medication administration, results of assessments, and responses to treatment and other interventions—for a variety of purposes. Documenting information accurately and comprehensively ensures continuity of care, supports clinical decision-making, manages risk, and aids in evaluating the effectiveness of interventions.
The ANA has articulated six principles for high-quality documentation by nurses (Table 14.7) (ANA, 2010). This module demonstrates how these principles apply to documentation in the real world, as well as the various purposes and components of high-quality documentation.
| Principle | Explanation |
|---|---|
| 1. Documentation characteristics | High-quality documentation has several identifiable characteristics, including accessibility, completeness, legibility, and timeliness. |
| 2. Education and training | Nurses must receive sufficient education and training to ensure they are capable of performing high-quality documentation. |
| 3. Policies and procedures | Nurses must know and apply all of their organization’s policies and procedures relevant to documentation. |
| 4. Protection systems | Documentation must happen in systems that have been designed to ensure patient security and confidentiality. |
| 5. Documentation entries | Each documented entry must be authenticated and made in a standardized manner, with an accurate date and time stamp. |
| 6. Standardized terminologies | All nurses must use a standardized, agreed-upon terminology to describe the steps in the nursing process and patient symptoms and conditions. |
Link to Learning
The ANA’s six principles for nursing documentation are explained in this pamphlet along with a variety of recommendations for effective documentation.
Documenting Data Collected
As discussed in 12.3 Collection of Assessment Data, data consist of information that nurses gather about a patient’s health status. Baseline and ongoing assessments of the patient’s health status, including the recording of vital signs such as blood pressure, heart rate, temperature, and respiratory rate are among the most critical aspects of nursing documentation. Nurses also meticulously document specific assessments related to the patient’s condition, such as pain levels, mobility, nutritional status, and mental health assessments. These data form the foundation upon which treatment plans are developed and adjusted.
Another crucial aspect of nursing documentation is the administration of medications and treatments, which must include the time, dosage, route, and any patient reactions or side effects. This information is vital for managing the patient’s treatment and ensuring other healthcare providers are aware of the patient’s current interventions.
Documentation extends to patient education and understanding, with nurses recording the information provided to patients and their families, including instructions for care, explanations of procedures, and any educational materials. This aspect ensures that patient education is integrated into the care plan and that there is a record of the patient’s understanding and consent for various aspects of that care.
Changes in Patient Condition
Documenting changes in a patient’s condition, whether improvements or deteriorations, is a fundamental responsibility of nursing practice. Changes in patient condition can range from subtle shifts in vital signs to more significant clinical changes, such as adverse reactions to medications, improvement or worsening of symptoms, or positive responses to treatment interventions.
There are two main reasons why documenting changes is an essential part of patient care:
- It guides clinical decisions by helping the care team recognize patterns or trends in a patient’s condition, which is crucial for early intervention if adverse developments arise.
- It ensures effective communication within the healthcare team, keeping all members aware of the patient’s current status and recent changes, even those without direct contact with the patient. Lastly, it provides a clear and objective record that can be referenced in future care planning and evaluation.
In the Clinical Judgment Measurement Model (CJMM), documenting changes in a patient’s condition aligns with the steps of Recognizing Cues and Analyzing Cues. By systematically recording changes, nurses gather crucial information (cues), which is then analyzed to inform clinical judgments and interventions, ensuring that patient care is responsive, timely, and based on the most current and accurate information available. (Next Generation NCLEX, n.d.).
Life-Stage Context
Changes in Patient Condition across Different Age Groups
Nurses must consider the unique physiological and developmental characteristics associated with different life stages when documenting changes in a patient’s condition. This attention to age-specific details is crucial in accurately interpreting and responding to changes in patient condition.
- Neonates and infants: In neonatal and infant patients, subtle changes can be significant. For example, a slight change in feeding patterns, activity level, or cry pitch may indicate discomfort or illness, as infants cannot verbally communicate their symptoms. Nurses should closely monitor and document parameters such as feeding tolerance, stool and urine output, and skin color, as these can be early indicators of changes in condition.
- Children: With pediatric patients, especially those with limited communication skills, changes in behavior or play can be important cues. A child who is usually active but becomes withdrawn or shows changes in eating and sleeping patterns may be experiencing discomfort or illness. Documenting these behavioral changes alongside physical symptoms is vital in assessing the child’s overall condition.
- Adolescents: Adolescents may be more capable of expressing their symptoms, but they can also be reluctant to share concerns about their health. Nurses should document both the verbalized symptoms and observed behaviors, such as changes in social interaction or school performance, which can be indicators of underlying health issues.
- Adults and older adults: In adults, especially older patients, nurses should be vigilant about documenting even minor changes in condition, as they can be early signs of more serious health concerns. For example, slight confusion or memory lapses in an older adult patient might be the first signs of a urinary tract infection or other systemic issue. In these age groups, it’s also important to document baseline cognitive function to recognize any deviations.
Across all life stages, effective documentation of changes in a patient’s condition includes noting physical symptoms and observing and recording behavioral and cognitive changes. This comprehensive approach ensures that care is tailored to the specific needs of each age group, enhancing patient safety and care quality.
Documenting Risk Management
Risk management in nursing involves identifying, assessing, and taking steps to minimize risks that might harm patients or healthcare providers. Documentation provides a detailed record of potential risks and the measures taken to manage them. Effective documentation in risk management promotes patient safety, enhances the quality of care, and serves as a legal record. It also enables healthcare providers to track the effectiveness of interventions designed to mitigate these risks.
Potential Safety Concerns
Nurses are often the first to identify situations that may pose a risk to patient safety, such as environmental hazards, the potential for medication errors, or risks associated with patient mobility. For example, a nurse might document observations of a cluttered room that could increase the risk of falls for an older adult patient. This documentation is vital for initiating immediate actions to remove the hazard and informing the broader healthcare team about the risk. Another example is the documentation of potential allergic reactions to medications. If a nurse observes signs of an allergy, such as a rash or difficulty breathing, after medication administration, this information should be documented immediately. It is crucial for healthcare providers to make informed decisions about medication adjustments and to monitor for similar risks in the future.
Development of New Problems
Nurses also document the development of new problems or complications in patient care, which is essential for effective risk management. For instance, if a patient develops bedsores due to limited mobility, this must be documented as a new problem. The nurse would record the location, size, and appearance of the bedsores, along with any interventions applied, such as repositioning the patient or wound care. This documentation facilitates appropriate ongoing care and serves as a record for evaluating the effectiveness of the interventions and adjusting care plans as needed.
Documenting Evaluation of Intervention
Evaluating the results of nursing interventions is a critical component of the nursing process, allowing healthcare professionals to assess the effectiveness of their actions and make necessary adjustments to patient care. Documentation plays a crucial role in this evaluation phase, as it provides a detailed record of the interventions implemented and their outcomes. Through meticulous documentation, nurses can track the progress of a patient’s condition, analyze the effectiveness of treatments, and provide a basis for future care decisions. This process is integral to ensuring that patient care is evidence-based, patient-centered, and continuously evolving to meet the individual needs of each patient.
In the context of the CJMM, documenting the evaluation of interventions aligns with the steps of Generate Solutions, Take Action, and Evaluate Outcomes. Accurate and comprehensive documentation allows for an informed evaluation of the care provided and supports the ongoing process of clinical judgment and decision-making (Next Generation NCLEX, n.d.).
Outcome Achievement
When documenting the evaluation of interventions, one key aspect is to record whether the intervention has achieved its intended outcome. For example, if a patient is experiencing postsurgical pain, a nurse might administer pain medication as an intervention. Documenting the patient’s pain level before and after medication administration provides clear evidence of whether the intervention was effective. If the pain level decreases significantly, it indicates the success of the intervention. Conversely, if there is no change or an increase in pain, it may signal the need for reevaluation and potential changes in the pain management plan. Similarly, in cases of chronic conditions such as hypertension, nurses document the patient’s blood pressure readings before and after implementing lifestyle changes or medication adjustments. This ongoing documentation helps assess the long-term effectiveness of the intervention and guides future care planning.
Document Education Provided
Another essential aspect of documentation in the evaluation phase is recording the education provided to patients and their families. Educating patients about their condition, treatment plans, and self-care is one of the most important aspects of nursing care. Documenting educational interventions, including the topics covered, the materials used, and the patient’s response, is necessary for several reasons.
First, it ensures continuity of care. If a patient is transferred to another unit or readmitted later, the next care team can see what education the patient has already received and build upon it. Second, it serves as evidence of patient teaching, which is often required for compliance and accreditation purposes. For example, if the nurse teaches a patient with diabetes how to manage their blood sugar levels through diet and medication, documenting the education session records what was taught and demonstrates the patient’s understanding and engagement with their care plan.
Accurate Description of Care
Accurate documentation of care is essential in nursing, serving both medical and legal purposes. It ensures continuity of care by providing subsequent caregivers with a comprehensive understanding of a patient’s history, current condition, and the care they have received. Accurately describing care also protects nurses and healthcare facilities legally, as medical records can serve as evidence in cases of disputes or litigation. The legal role of these documents emphasizes the necessity for precise, clear, and complete documentation of all elements of patient care.
It can be helpful to see how the components of accurate documentation would look in the context of a specific patient. The following is an example to consider that will be revisited throughout the chapter to help demonstrate key concepts: Mr. Ahmed is a 70-year-old patient admitted to the hospital with congestive heart failure (CHF). His condition requires careful monitoring, medication management, and patient education regarding lifestyle changes to manage his CHF effectively (Cleveland Clinic, 2023).
What You Did
The nurse must accurately document actions taken as part of patient care to establish a clear record of all interventions, treatments, and procedures performed. This information enables the patient’s healthcare providers to track the progress of care, evaluate the effectiveness of interventions, and identify deviations from the planned course of treatment. Accurate documentation also supports accountability by clearly documenting the responsibilities of each healthcare provider involved in the patient’s care.
In Mr. Ahmed’s case, documenting “what you did” would require the nurse to record all actions taken as part of providing his care. For example, if the nurse administered a diuretic to manage his fluid retention, the documentation should include the name of the medication, dosage, route of administration, and time given. See Table 14.8 for an example of how what you do may be documented.
Nursing note: 0800
|
What You Observed
Documenting “what you observed” focuses on the nurse’s assessments and observations about Mr. Ahmed’s condition. This includes changes in his symptoms, responses to treatments, and any side effects observed. See Table 14.9 for an example of how what you observe may be documented.
Nursing note: 0800
|
Chart in Real Time
Charting in real time is necessary for maintaining accurate and up-to-date patient records. In Mr. Ahmed’s case, this would mean documenting assessments, interventions, and observations as soon as they occur. See Table 14.10 for an example of how the nurse may chart medication administration in real time.
Nursing note: 0800
|
Chart Precautions and Preventative Measures
Documenting precautions and preventative measures is key in managing Mr. Ahmed’s CHF. This could involve noting the implementation of low-salt diet instructions, fluid restriction guidelines, and daily weight monitoring to track fluid status. See Table 14.11 for an example of how the nurse may chart precautions and preventative measures.
| Nursing note: 0800 Administered furosemide 40 mg orally. Patient educated about potential side effects, such as dizziness, and the importance of monitoring output. Provided written instructions for a low-sodium diet. Advised to limit fluid intake to 1.5 liters per day. Set up daily morning weight monitoring to track fluid changes. Patient verbalized understanding of education. |
In each documentation aspect within Mr. Ahmed’s chart, the focus is on providing a detailed and accurate account of the care provided to the patient, ensuring that all healthcare team members are informed and aligned in their approach to managing his CHF. This comprehensive documentation approach is integral to delivering high-quality, patient-centered care.
Appropriate Terminology
In nursing documentation, using appropriate terminology is essential for clear and effective communication among healthcare providers. Appropriate terminology ensures that documented information is accurately conveyed and universally understood in the healthcare setting. This includes documenting with medically accepted terms, approved abbreviations, and providing complete descriptions. It also requires a focus on documenting care provided, rather than conflicts or interpersonal issues, to maintain professionalism and a patient-centered approach.
Use Approved Abbreviations
Using approved abbreviations in medical documentation is necessary, but the nurse must only use widely recognized and accepted abbreviations within the healthcare community. For example, “BID” is a commonly accepted abbreviation meaning “twice daily.” The term comes from the Latin phrase bis in die. A sample documentation might read, "Administered 5 mg of metoprolol PO BID," which is clear and concise (Mennonite College of Nursing, n.d.). Using lesser-known or outdated abbreviations can cause misunderstandings and lead to errors in patient care. Nurses should always refer to their facility’s approved abbreviation list and avoid using nonstandard abbreviations to prevent confusion or mistakes.
Link to Learning
This comprehensive guide to nursing abbreviations and acronyms is maintained by the Mennonite College of Nursing.
Chart with Complete Descriptions
Although abbreviations are useful for efficiency, it’s equally important to provide complete descriptions when necessary, especially for complex or unusual situations. For instance, instead of simply documenting “wound care performed,” a more descriptive entry would be, “Cleaned wound with saline, applied new dressing, no signs of infection noted, patient reports pain level 2/10.” This level of detail ensures that anyone who reads the chart understands the care provided and the patient’s current condition. This level of detail is especially helpful when a patient’s condition is changing, or there is something out of the ordinary about their care—for example, an uncommon treatment.
Chart Care, Not Conflicts
When documenting in patient charts, the focus should always be on the care provided and the patient’s response to that care, not conflicts or interpersonal issues that may arise. If there’s a disagreement with a patient about a treatment plan, the nurse’s documentation should include the facts of the situation rather than the disagreement. The nurse should stick to objective information and avoid opinions. This approach maintains professionalism and ensures that a patient’s chart is a factual record of care and responses, not a subjective log of disagreements or conflicts.
Patient Conversations
Handling Argumentative Patients
After reading this conversation between a nurse and a patient who has been prescribed a new medication, decide what the nurse should document and what does not need to be documented.
Nurse: Mr. Lee, this medication is important for managing your condition. It can significantly reduce your symptoms.
Patient: But I read about all these side effects online and I’m really worried about them.
Nurse: It’s good to be informed. However, the benefits of this medication are significant for your long-term health—
Patient: (interrupting): But what about the risks? I heard it can even cause liver problems.
Nurse: Mr. Lee, please let me finish explaining. These benefits include improved blood pressure and reduced risk of heart-related issues. Yes, there are potential side effects, like with any medication, but they are relatively rare. We monitor your health closely to mitigate these risks.
Patient: I just don’t want to risk more health problems. Can’t we try something else?
Nurse: I understand your concerns. There are alternatives, but they may not be as effective for your specific condition. Let’s go through them together and discuss with your provider. We want to ensure you’re comfortable and well-informed about your treatment.
Patient: Okay, I’m willing to listen, but I’m still not sure about this.
Nurse: That’s perfectly fine, Mr. Lee. Let’s explore all your options and find a solution that works best for you. Your comfort and health are our top priorities.
Scenario follow-up: The nurse should document this conversation by focusing on the care aspects: for example, "Discussed treatment options with Mr. Lee, who expressed concerns about potential side effects of the prescribed medication. Reviewed benefits and risks. Patient hesitant about starting medication due to side effect concerns. Arranged for consultation with the provider to discuss alternative treatments and ensure patient comfort with the plan." This style of documentation maintains professionalism, focusing on the care and treatment decisions rather than the tension in the conversation.
Source-Oriented Documentation
A traditional method of recording healthcare information is known as source-oriented documentation (Table 14.12). Each healthcare professional, such as nurses, providers, therapists, and others, documents their findings and interventions in separate sections or forms. This approach makes it easy to identify the source of each piece of data. The advantage of source-oriented documentation is the clear delineation of information by discipline, making it faster and more efficient to locate specific data. It provides a detailed and chronological account of the patient’s healthcare journey from various professional perspectives. However, a drawback is that it can lead to fragmented information, as separate documentation by different providers can make it challenging to get a comprehensive view of the patient’s overall status. Additionally, redundancy and repetition may occur when multiple providers document similar information (Almasi et al., 2019).
| Documentation Type | Purpose | Advantages | Disadvantages | Tips for Effective Use |
|---|---|---|---|---|
| An admission sheet | Initial record upon admission; includes medical history, medications, allergies, reason for admission | Baseline for patient condition; crucial reference throughout hospital stay | Can become outdated if not regularly updated | Ensure accuracy and completeness; note changes promptly |
| A flow sheet | Brief form with essential patient information | Efficient tracking of specific data over time; easy-to-spot trends | Can miss important details if not concise | Focus on key information; update frequently |
| A narrative note | Detailed account of patient’s condition, care, and response in paragraph form | Provides context and detailed explanations; allows for more in-depth documentation | Time-consuming to write and read; important information can be buried | Be clear, concise, and focus on significant events; organize chronologically; use clear language and avoid medical jargon |
Problem-Oriented Documentation
An organized approach to recording patient care that focuses on the individual problems a patient may have is called problem-oriented documentation. It differs from source-oriented documentation because it organizes information around patient issues rather than the source of information. This method enhances the coherence and focus of patient records, allowing healthcare providers to track the progress of each problem, the interventions implemented, and the outcomes (Altman et al., 2023). Problem-oriented documentation typically leads to better communication among healthcare team members because it provides a clear, concise overview of patient issues, interventions, and outcomes. However, it also requires a thorough understanding of patient problems and consistent documentation practices to maintain effectiveness.
Problem-oriented documentation also comes in different forms, including the SOAP and PIE methods, focused charting, charting by exception, and the case management model.
Link to Learning
In this video by Mometrix Nursing, you can learn some tips for creating SOAP notes.
SOAP Method
The SOAP method is a widely used form of problem-oriented documentation, structured into four components: Subjective, Objective, Assessment, and Plan (Sindhu, 2020).
- Subjective: This section records the patient’s perspective, including symptoms and feelings.
- Objective: This section documents objective data, such as vital signs, physical exam findings, and lab results.
- Assessment: This section documents the nurse’s clinical judgment about the patient’s condition based on subjective and objective information.
- Plan: This section outlines the plan of care or interventions to address the patient’s problem.
The SOAP method is beneficial for its structured and comprehensive approach to documenting patient care; however, it requires careful attention to ensure all aspects of the patient’s condition are accurately captured. An example SOAP note could look like Table 14.13.
| Subjective | Patient reports worsening SOB and fatigue over the last forty-eight hours. |
| Objective | Vital signs: BP 150/95, HR 110, RR 28, O2 sat 89 percent on room air. Auscultation reveals bilateral crackles in lung bases. |
| Assessment | CHF exacerbation |
| Plan | Notify provider, stat chest x-ray, supplement oxygen via nasal cannula |
Sometimes, the SOAP method will be expanded to the SOAPIER method. The SOAPIER method extends the traditional SOAP format to enhance documentation by integrating ongoing evaluation and revision, ensuring a dynamic approach to patient care management.
- Intervention: Documents specific actions taken as part of the plan, including procedures performed, medications administered, and therapeutic interventions.
- Evaluation: Describes the patient’s response to interventions, assessing their effectiveness and any changes in the patient’s condition.
- Revision: Documents any adjustments made to the plan based on evaluation findings or changes in the patient’s status.
An example SOAPIER note could look like Table 14.14.
| Subjective | Patient reports worsening SOB and fatigue over the last forty-eight hours. |
| Objective | Vital signs: BP 150/95, HR 110, RR 28, O2 sat 89 percent on room air. Auscultation reveals bilateral crackles in lung bases. |
| Assessment | CHF exacerbation |
| Plan | Notify provider, stat chest x-ray, supplement oxygen via nasal cannula |
| Intervention | Administered supplemental oxygen at 2 L/min via nasal cannula. |
| Evaluation | After one hour, patient’s O2 saturation improved to 94 percent, with decreased respiratory distress noted. |
| Revision | Revised plan to continue oxygen therapy at 2 L/min and monitor closely for further improvement. |
PIE Method
The PIE method involves another acronym, with each letter representing a component of the documentation (Almasi et al., 2019):
- Problem: The nurse identifies the patient’s problem.
- Intervention: The nurse documents the actions taken to address the problem.
- Evaluation: The nurse describes the patient’s response to the intervention.
This method ensures a direct link between identified problems and the care provided. Its focus on ongoing evaluation makes it helpful when adapting the care plan, but it can be time-consuming due to the level of detail required. An example of a PIE method note could look like Table 14.15.
| Problem | Uncontrolled hypertension |
| Intervention | Education on the importance of medication adherence and compliance with lifestyle change recommendations. |
| Evaluation | After two weeks of intervention, patient BP still elevated at 160/98. Medication adjustment may be necessary. |
Focused Charting
Focused charting involves documenting care and observations based on specific patient concerns or behaviors. A note typically includes four parts, which form the acronym F-DAR (Magbanua, 2024).
- Focus: Briefly note the main purpose of the note or patient concern.
- Data: Information about the patient’s condition or behavior.
- Action: The interventions or care provided.
- Response: The patient’s response to the action(s) taken.
Focused charting is beneficial for its patient-centered approach and flexibility, allowing nurses to adapt the documentation to the specific needs and issues of each patient. A note using the F-DAR format could look like Table 14.16.
| Focus | Patient reports pain at incision. |
| Data | Patient rates pain at 8/10. Incision site is red, warm, and there is a small amount of purulent drainage. |
| Action | Wound cleaned and dressed, antibiotics administered per provider order. |
| Response | Reassessed one hour later, patient reports pain 4/10. |
Charting by Exception
Charting by exception is based on the assumption that unless a deviation from standard or expected outcomes is observed, a patient’s care is following the established plan (Roberts, 2020). Because only significant findings or exceptions to norms are documented, this method saves time and reduces the volume of paperwork. However, this approach may overlook important details that do not qualify as exceptions but are still relevant to patient care.
Case Management Model
The case management model involves comprehensive documentation that coordinates and tracks patient care across different stages and settings. This model focuses on continuity of care, especially for patients with complex or long-term health needs. It encompasses a broad overview of patient care, from admission to discharge and beyond. The challenge with this model is maintaining a high level of detail over extended periods and across various healthcare settings (Registered Nursing, 2023).