If It Wasn’t Documented It Wasn’t Done

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Who You’ll Hear

Kati Kleber, MSN RN – Nurse educator, former cardiac med-surg/stepdown and neurocritical care nurse, author, and speaker.

Elizabeth Mills, BSN RN CCRN – highly experienced neurocritical care nurse, current Stroke Navigator for a Primary Stroke Center.

What You’ll Learn:

• Why Documenting Matters
• Tips

Why it matters

Document with the mentality that someone is going to read this in a deposition in 5 years. In 5 years, are you going to remember a really boring, normal day? Paint a clinical picture – why did you give that PRN med? What was their response? Even if you did nothing wrong, maybe the next day something happens and they are looking closely at your documentation and you need to be able to speak to it.

Tips

• Don’t zone-out of the documentation classes
  • Pay attention for requirements
    • Don’t document unnecessarily
    • If you document by exception (for example by saying “Within Defined Limits”) know what those defined limits are, so you’re not double documenting
    • Pull your assessment policy
  • Pay attention for short cuts
    • Efficiency is key! The faster you document, the less time you spend doing it. That doesn’t mean that you will document less, you’ll just
    • Spend time getting to know your EHR back and forth so you can navigate and document quickly
• Use the keyboard as much as possible; using the mouse slows you down
• Have a consistent routine so you don’t miss anything
• Chart in real time when possible
  • You tell yourself you’ll remember, but you won’t
  • Rarely will you have enough uninterrupted time to sit down and chart everything
  • If you’re able, do so while in the patient’s room – if you forget something or need to check something, you can do that really quickly
• Weave charting into your tasks and trips
• Only copy and paste your own documentation, and if you’re allowed to by policy
  • “Just because it was documented doesn’t mean it was done”
• Just because a coworker documents something does not mean it was the correct way
• Document the abnormals in real time and go back to fill in the blanks later
  • Provides time stamp and important information
• Always chart objectively
  • If you walk into a room and see a patient on the floor, don’t chart that they fell.. chart that they are on the ground
• Only use acceptable abbreviations in official charting
• Following up on an abnormal finding is ESSENTIAL
  • Pain
  • Vitals
  • Need for restraints
  • PRN meds
• Chart when you’ve notified the physician
  • Can also chart when MD rounds
• Use the keyboard as often as possible
  • The mouse will slow you down
• NEVER chart in advance
• If possible, create templates for care plans and fill in the blanks
• Create a checklist on your report sheet when you start out until you get it memorized
  • Tele
  • Assessments
  • Care plans
  • Education
  • IV’s
  • Meds

More resources

• Why Are Nurses Always on the Computer!? – FreshRN Blog, a comprehensive list of typical nursing documentation requirements
• Do’s and Don’ts of Documentation – NSO
• 7 tips on avoiding malpractice claims: careful practice and documentation help keep you out of court – Lippincott
• Nurses: What is the Most Important Documentation Advice? – Answers from an attorney