Keeping good nursing records is essential, as it ensures a high standard of care is provided to residents while also acting as proof of care should any lawsuits occur. One of the best ways to ensure that nurses follow best documentation practices is to use effective nursing documentation examples to help get them prepared for real-life scenarios.
Most facilities have their own policies and procedures regarding how nurses document care, including who received care (resident), when the care took place (date), what treatment took place, and who administered the therapy (signature). Facilities will often provide their own nursing documentation examples to newly hired nurses, so they understand and document care using the facility’s standardized format, making it easier for all staff members to be on the same page.
Here we will provide guidelines about nursing documentation, what is to be included, how to avoid pitfalls, and the best resources available for improving your process.
What Type of Resident Information Is Documented?
While nursing documentation may slightly differ according to the state and facility, most will document the following clinical nursing documentation data:
- Resident assessments
- Vital signs
- Changes to residents’ weight and height
- Type of medication and administration
- Intravenous and blood product therapy
- Nurse’s notes
- Physician orders and accompanying notes
- Therapy notes
Facilities prefer to use long term care EHR systems over handwritten notes, as they allow for more accurate documentation and improved workflow efficiency. Also, all resident data included in long term care software is readily available when needed.
Of course, in the case of a computer system failure, nurses must return to relying upon handwritten documentation to detail the essential facts in concise sentences, though they are later transferred to the long term care EHR system once it is up and running again.
In addition to documenting the clinical notes mentioned above, long term care facilities must also include daily nursing notes that are specific to Skilled Nursing Facilities (SNFs), such as:
- System assessments,
- Activities of Daily Living (ADLs)
- Changes in residents’ condition
- Resident attendance and response to therapy (physical, occupational, and speech)
What Are the Regulations of Nursing Documentation?
According to the American Nurses Association (ANA) standards of nursing practice, nursing documentation notes should follow each state’s requirements according to the Nursing Practice Act (NPA), which defines safe and competent nursing practices. While the NPA may differ according to each state, the general requirements for how nursing notes are that they should be:
- Objective and not critical or subjective
- Clear, concise, and comprehensive
- Accurate, truthful, and honest even if an incident or error occurs
- Representative of observations rather than guesswork
- In accordance with state laws, forms, methods, systems, standards, and facility policies
Nursing notes must also include:
- The nurse’s response to the care and actions taken
- A complete record of all nursing care and treatment must be documented, detailing all assessments, health issues, personalized care plan, actionable treatments, and evaluation
- All relevant nursing documentation
Failure to follow these guidelines can result in documentation errors that subsequently lead to adverse medical errors. Hence, facilities should provide adequate nursing documentation training to mitigate these errors.
Common Nurse Charting Errors
For healthcare providers, accurate nurse charting documentation can be the difference between life and death. Therefore, facilities must provide nursing documentation examples so that nurses can understand what is expected of them. For example, in Texas, facilities offer nurse charting training by detailing: the federal and state laws to which they must adhere; facility standards and rules; common errors and ways to improve documentation; and sample nurse notes used for training purposes.
Contrary to the popular belief that documentation errors occur because nurses are incompetent or reckless, nurse charting errors often arise because nurses do not receive adequate Electronic Medical Records (EMR) or EHR training. In addition, faulty systems and fragmented facility processes can further exacerbate charting errors, resulting in inaccurate data entries.
Therefore, rather than blaming nurses, facilities must address their failed processes before finding appropriate solutions to improve their training procedures. Some examples of the most common nurse charting documentation errors are:
- Illegible handwritten nursing notes: These can lead to mixed messages regarding a resident’s medical history or care, for example, charting “hyper” instead of “hypo.”
- Failure to capture important entry details: Failing to document important nursing notes like the date, time, and medical entry signature can lead to medical errors and serious consequences.
- Lack of documentation: Nurses must document all previous medications or treatments administered within the facility and by other healthcare providers. Failure to do so is another way to cause medical errors.
- Incomplete or missing documentation: Clinicians need to know each resident’s complete medical history to make informed medical decisions based on data rather than guesswork.
- Not adding entries during the point of care: If nurses do not enter or update their nursing notes at the point of care (while beside the resident), they may forget specific details, and that can lead to inaccurate data entries.
- Not documenting care objectively: Nursing notes must be accurate and precise, based on observations and facts and not opinions or guesses.
- Not questioning inconclusive orders: Despite the best efforts of clinicians, they are human and can make mistakes. If a nurse has any reservations about a specific treatment, they should voice their concerns or risk the facility making medical errors.
- Incorrect use of abbreviations and acronyms: There are many abbreviations and acronyms in nursing documentation, which can be challenging for a new nurse to keep up with. To help stay on top of things, they can use the Mennonite College of Nursing (MCN) comprehensive list of nursing acronyms and abbreviations, which includes the acronyms accepted all across America.
- Wrong data entries: If nurses are not diligent, they may enter information into the wrong resident chart or care plan.
Any combination of these nursing charting errors can lead to adverse medical errors, leaving the facility vulnerable to liability and malpractice lawsuits. This is all the more reason why providing relevant EMR and EHR training to nurses is imperative for residents’ health and safety and the facility.
If you want to learn more about nursing documentation and how long term care software can improve your facility’s processes, contact us here.
6 Nursing Documentation Examples PDF Resources and Tips
Like other healthcare providers, long term care staff work in shifts. Therefore, it is imperative that when a nurse starts a shift, they are confident in the nursing documentation and its accuracy. With accurate documentation, clinical staff can effectively communicate a resident’s condition to their shift replacement via their care plan.
Listed below are some tips nurses can use to protect themselves and their facility while also improving the accuracy of their nursing documentation:
- Prioritize Nursing Documentation Time
A nurse has many responsibilities, and at times, it may seem like they are too busy to document nurse notes. However, they must always prioritize nursing documentation, especially when there are changes in code status, admissions, transfers, verbal orders, abnormal vitals, or even changes in medication. Doing so ensures all critical data is captured accurately.
- Be Detailed and Specific
When documenting assessments and notes, nurses should be specific and concise, detailing what, when, where, and why they are documenting a particular treatment. It is best to avoid using general language, as this can lead to unnecessary confusion. If nurses are unsure how to be precise, they can practice activities found in nursing documentation examples PDF workbooks, such as Documentation in Nursing Practice.
- Know the Facility’s Procedures and Guidelines
Nurses must protect themselves from liability lawsuits, which means they must know the facility’s and state nursing documentation guidelines. Some nursing orientation training handbooks will include detailed nursing documentation examples, with helpful illustrations of completed documentation forms, such as initial and daily assessment forms, which fall within a nurse’s documentation responsibilities.
- Be Mindful of Allergies
An often overlooked nurse entry note is the residents’ allergy status. A physician needs this essential information to administer the proper medication, dosage, and treatment. Therefore, nurses must be mindful when filling out nursing charts to include all adverse allergy reactions and update any new information in the long term care EHR.
If a nurse is unsure how to document allergies, they can refer to online examples and functions of nursing documentation for more information on how to correctly document care.
- Nurse Charting Timeline
Nurse charting is very time-specific. It cannot be done in advance and should not be done after the point of care, as either option puts the nurse at risk of entering inaccurate information. Should erroneous information be entered, the nurse must follow facility policies to correct any charts approved by management.
Efficient nursing home management software will have pre-built assessment templates that help to minimize errors and improve nurse charting accuracy. These valuable tools offer suggested problems and correlations templates so nurses can modify and personalize resident charts accordingly.
- Use the SBAR Approach
Facilities can encourage their nurses to use the SBAR approach: situation, background, assessment, and recommendation to better set expectations and ensure a resident’s charts are documented correctly in the nursing home software and the best practice steps are followed.
The Advantages of Using Nursing Documentation Examples
Nursing documentation is entered into a facility’s LTC software for accurate and convenient record keeping. The computerized documentation system allows caregivers to process, share, and access relevant information to provide residents safe and quality care. Effective nursing home charting software will also include helpful nursing documentation examples and templates for user-defined assessments so nurses can personalize a resident’s care plan efficiently without needing to sift through paperwork.
Updating nursing charts electronically via handheld devices connected to the care plan software allows nurses to reduce documentation errors significantly when modifying resident condition changes. It also speeds up the time required to document care, improves accuracy, and legibility.