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For new and experienced nurses, documentation in nursing is a primary responsibility in day-to-day tasks. And although the process can seem burdensome, it is quite necessary. Let’s dive deeper into what documentation in nursing is and why it is essential to resident care. 

Documentation in nursing is written evidence verifying all nursing activities that have been carried out for a patient or resident. It gives healthcare providers, including long-term care facilities, a paper trail of activities documenting whether nurses have followed their moral duties and clinical responsibilities when caring for patients or residents. Needless to say, nursing documentation must be accurate, well-written, and recorded promptly to minimize errors. 

When nurses are documenting information, there is a variety of patient data they must record including the following:

A nurse reviews her daily documentation in nursing tasks to ensure there are no errors.
For nurses, documentation in nursing is a primary responsibility in day-to-day tasks.
  • Patient care plans
  • Clinical nursing processes
  • Admission, discharge, transfer, and transport information
  • Patient or resident demographic data, including educational background, insurance information, and complete medical history 
  • Prescribed medications
  • Previous collaborations with other healthcare providers, physicians, and primary caregivers

While accurate documentation allows caregivers to make clinical decisions based on facts, it also improves communication between caregivers with the latest patient updates. Nurses regularly use patient care data to implement, plan, and evaluate patient care, making documentation in nursing critical to reducing clinical errors and adverse patient outcomes.

Besides improving communication between caregivers, there are several reasons why high-quality documentation in nursing is necessary, like the following:

  • Allows caregivers to gather essential information from nursing diagnoses to reveal potential health issues 
  • Provides caregivers with vital research data on related healthcare issues that can improve healthcare jobs 
  • Ensures the correct documentation in nursing data is accurate, which impacts  PDPM reimbursements and private insurance payouts 
  • Protects healthcare providers like long-term care facilities from unsafe nursing practices and potential liability or malpractice lawsuits

Because of these, healthcare providers must provide adequate training that is in line with federal and state regulations to improve nursing documentation processes and patient care. 

Understanding Nursing Documentation Standards

Now that we have a better understanding of why documentation in nursing must be accurate, we will discuss nursing documentation standards that healthcare providers must adhere to. 

When it comes to documentation in nursing, the first rule of thumb for any nurse is to know the governing regulations, state practices, and institution policies and procedures. 

To meet the public’s high expectations while ensuring patient safety in nursing care, healthcare providers like long-term care facilities must follow the regulation boards that govern the industry, such as the Nursing Practice Act (NPA) and the Board of Nursing (BON). 

Each state sets its laws to govern nursing practices outlined in the Nursing Practice Act (NPA). For example, details on California NPAs, healthcare providers, and caregivers can be found in the regulations and codes that describe practical nursing practice information, advice, and guidelines to registered nurses, employers, educators, and the general public.

The practices outlined in the NPA are interpreted in accordance with state regulations and enforced by the NPA alongside the legislative Board of Nursing, which disciplines nurses who violate nursing regulations and pose a threat to the public. For instance, Texas-based providers and caregivers can view the latest (and previous NPA) laws and rules relevant to them to stay updated with any legislative changes impacting nursing care.

While each state’s NPA varies, they generally provide guiding principles that define the following:

  • Composition of board members
  • Terms and phrases for the intent of the law
  • Nursing school educational program standards
  • Scope of nursing practice, including documentation in nursing
  • Grounds for violation and disciplinary actions
  • License processes

The BON regulates nursing practice by stipulating NPA guidelines while protecting US citizens’ health, safety, and welfare from inappropriate or low-standard nursing care, while the BON board members consist of governors, senators, and reputable industry professionals, like doctors and nurses.   

Suppose healthcare providers or caregivers want to learn more about their state’s NPA or BON. In that case, they can use this Nurse Practice Act Toolkit to find information about regulations, NPA courses, educational resources, and contact information for BONs. 

In addition to state laws, nurses must also abide by institutional policies and procedures and any guidelines from applicable specialty organizations. An example of such an organization would be the Emergency Nurses Association (ENA), which represents emergency nursing and provides resources, a code of ethics, and best practices that are essential in the emergency nursing profession.

It is worth noting that state laws override the institution when state laws and institutional policies conflict. Furthermore, while institutional guidelines are used to improve nursing practices and standards of care, they are not legally binding like state laws. 

Contact us here if you want to enhance your nursing documentation processes.

9 Tips for Meeting Nursing Charting Guidelines 

By now, we have a solid understanding of the importance of following nursing charting guidelines to achieve seamless nursing care and management. Here it can be added that, on the legal side, accurate documentation in nursing protects the healthcare provider and the caregiver when documentation is needed as part of a legal defense to show proof of professionalism and proper actions.  

Those are pretty high stakes. To ensure that the nursing documentation is accurate, healthcare providers and caregivers should follow these nine nursing charting guidelines:

A nurse is reading about the national nursing documentation standards to ensure his documentation is correct.
To ensure patient safety, caregivers must understand nursing documentation standards.
  1. Check all notes are correct before making an entry: All essential patient information, like the correct spelling of the patient’s name and date of birth, must be entered correctly. This makes it easier for different healthcare providers to link patient healthcare records more efficiently and effectively.
  2. Ensure all documentation in nursing notes reflects accurate nursing processes: This includes documenting everything that is seen, heard, or done while avoiding inappropriate or subjective opinions about patients or other team members. 
  3. Document all patient responses: For instance, when a patient refuses treatment or medication, nurses must report this behavior to the patient’s physician or the shift manager. 
  4. Chart promptly when an observation is made or at the point of care: This ensures that all actions are documented with detailed notes while minimizing the likelihood of forgotten details.
  5. Track test results and reports: All findings must be appropriately communicated and documented in the patient’s health information record. 
  6. Be as descriptive as possible: Ensure that all nursing documentation is accurate by avoiding repetitive copying and pasting. This is especially important when documenting high-risk information, such as laboratory results, radiology reports, and drug formulations. 
  7. Include patient communication: A part of upholding high nursing documentation standards is including educational materials for the resident or their families regarding treatment or medications. This ensures that the correct information is passed onto the patient, resident, or their families, so they have a better understanding of their care while reducing complaints and concerns. 
  8. Document delegated tasks: There will be instances when nurses may need to delegate tasks, such as during a shift change. To ensure the nursing documentation legal requirements are met, include verification on all delegated patient care-related tasks that other team members complete. 
  9. Correct errors promptly: Even the most dedicated nurses may make errors from time to time. Correcting charting errors per the organization’s policies and procedures is vital while ensuring that late entries are correctly recorded. 

While charting may seem repetitive, the highest quality of documentation in nursing is crucial in preventing malpractice accusations while ensuring the best care for patients. Therefore, to uphold high nursing documentation standards, nurses must ensure their nursing practices are consistent with the patient’s personalized care plan while meeting federal, state, and the organization’s professional and ethical guidelines. 

Switching to Electronic Documentation in Nursing

The importance of nursing documentation is not lost on modern facilities, which have changed their documentation in nursing processes by switching from paper charting to long-term care software. By switching from paper to electronic, healthcare providers have utilized the built-in software processes that allow caregivers to customize their EHR functions. 

Two physicians are discussing the facility's nursing charting guidelines to ensure the nursing care and management meets national standards.
Following nursing charting guidelines makes nursing care and management seamless.

Thanks to this technology, caregivers can set automatic alerts when a patient’s condition changes so that other team members will be notified. Even during shift changes, all authorized caregivers are updated with the latest information, minimizing clinical errors while tailoring to each resident’s unique needs. 

Additionally, many senior care software systems are also cloud-based, which means caregivers can access patient data from any device connected to the long-term care EHR. This also improves communication between caregivers, as patient data can be updated more regularly and during the point of care, thus, ensuring more accurate data. 

For more on recent trends in long-term care, read our blog and subscribe to the LTC Heroes podcast