Any seasoned registered nurse will know the importance of using a nurse charting cheat sheet as an tool to guide nursing documentation and charting best practices. Nursing cheat sheets provide detailed examples of nursing documentation and charting to help keep legal records of patient care, patient welfare, and recovery.
Nursing documentation can be burdensome due to the high volume of patient data that needs to be maintained and updated daily. Newly qualified nurses often struggle with charting and nurse documentation because their nursing school may not have provided adequate nurse charting and documentation training.
To further complicate matters, facilities do not always have the same long term care software. This means new nurses must learn how to chart effectively and quickly while also learning to use the facility’s long term care EHR.
For these reasons, a nurse charting cheat sheet has become a popular tool to educate nursing staff so they can accurately document patient care. But what is nursing documentation, and why is it so important?
What Is Nursing Documentation?
Nursing documentation serves two primary purposes:
- It provides an accurate record of all medical care given to a patient. In the case of a legal dispute, healthcare facilities need to provide adequate documentation to support that proper care was given. If a patient or their family submits an official complaint against a nurse, the staff can refer to its documentation and share crucial details of what actually happened during their shift.
- It gives caregivers critical medical information, thus allowing them to make informed medical decisions. If care is forgotten or incorrectly documented, caregivers will not have access to accurate patient data and will not know what care and treatments have taken place. This increases the likelihood of medical errors leading to adverse patient outcomes.
Healthcare facilities have learned to standardize care documentation by way of using a nursing charting cheat sheet, which highlights the critical elements of patient care and the information to be recorded. Such cheat sheets typically cover the critical steps in patient care, detailing all treatments, medications, and other important medical information to ensure all care documentation is coherent for nursing staff and physicians, thus, improving communication between clinicians and the quality of patient care.
5 Legal Requirements for Nursing Documentation
Nursing documentation is essential for healthcare facilities because accurate patient records provide a safety net in legal disputes while minimizing medical errors. Long term care facilities must thus ensure the nursing documentation meets federal and state regulations by adhering to these 5 legal requirements for nursing documentation:
- All patient care and nursing assessments must be planned and documented in the facility’s nursing computer software or in an alternative documentation system.
- Should a patient’s health condition change, all new treatments and medication information must be added to the patient’s medical records. Any previous medical records must also remain, giving caregivers a comprehensive view of the patient’s medical history.
- Should a patient have ongoing health issues, like heart disease, or need ongoing assistance with Activities of Daily Living (ADLs), facilities must ensure the nursing staff enters regular documentation updates detailing all changes.
- Patient data is highly sensitive and confidential. Therefore, data should only be shared with authorized personnel. For this reason, well-designed nursing home management software programs include privacy and cybersecurity protection, ensuring strict security and authorization protocols are met.
- Patient data must be legible, clear, and accurate. Digital nurse charting cheat sheet templates give nurses a better understanding of accurate nursing documentation.
Many modern long term care facilities have invested in innovative nursing software programs with practical tools like the electronic Kardex, a clinical documentation tool that allows caregivers to document care more efficiently, accurately, and systematically, thus, improving the quality of data.
Contact us here if you want to learn how to improve your nursing documentation processes.
9 Tips for Using a Nursing Documentation Cheat Sheet
To prevent negligence and malpractice, facilities can improve nursing documentation by sharing a nursing documentation cheat sheet with their nursing staff to ensure the facility’s nursing documentation is standardized. This way, all clinical staff are trained to document and chart care using the same methods and techniques, making it easier for the team to work together
When adapting or improving a nurse charting cheat sheet, facilities can refer to the following tips to improve nursing documentation cheat sheet:
- Make nursing documentation your number one priority. Being “too busy” to document care is unacceptable and may cause medical errors and adverse patient outcomes.
- Avoid documenting general statements that can be misconstrued. Nursing documentation is used to communicate with all authorized clinical personnel. Therefore, the details must be clear and concise.
- Ensure all nursing documentation is accurate, legible, objective, and free from grammatical or spelling errors. Using long term care software to chart documentation will eliminate these issues because there are pre-determined options and a built-in spell check function for any additional notes that are included in the patient’s records.
- Avoid entering late entries or corrections. Should late entries and corrections be entered, they must follow the facility’s policy and procedures guidelines. While each facility’s guidelines may differ according to the state, most will follow the CMS’ Resident Assessment Instrument (RAI) manual.
- Highlight all allergies and ensure the full details are included.
- Never chart in advance. Instead, update and chart records in real-time while beside a patient or resident. This ensures maximum accuracy, especially if the nurse uses a portable, handheld device that allows her to move between patients.
- Be wary of charting patterns that are “too perfect.” Patient assessments, such as fall risk or skin assessments, must be carefully documented to prevent charting medical errors.
- Turn on important alert notifications via the nursing home software for all changes in condition and future steps. This will make it easier for nurses to observe any anomalies.
- Consult the facility’s nursing policy and procedure handbook to clarify abbreviations. Alternatively, nurses can refer to the Mennonite College of Nursing abbreviations and acronyms handbook to ensure the 5 legal requirements for nursing documentation are followed.
Another helpful resource that nurses can use is Documentation by the Nurse, published by the Texas Health and Human Services Quality Monitoring Program. This legal aspects of nursing documentation PowerPoint presentation includes details on the documentation basics, federal law requirements for documentation, national documentation standards, and documentation rules.
How a Nurse Charting Cheat Sheet Helps You Avoid Malpractice
It cannot be stressed enough just how vital proper documentation and charting are for healthcare and long term care facilities. The implications of improper or missing documentation can result in costly lawsuits for the nurse and the facility. If facilities want to avoid inadequate or inaccurate documentation lawsuits, they must train their staff accordingly. Perhaps the most viable way to avoid legal hassle is to provide a nurse charting cheat sheet that has accurate and complete patient charting documentation.
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