Weekly Tip: Nursing Documentation

Nursing Documentation: Whether you document electronically or on paper, documentation of patient care is a priority.  However, nurses constantly complain about spending too much time documenting and not enough time with their patients.  Let’s first look at the importance of documentation.  We’ve all heard the comments, “If it wasn’t documented, it wasn’t done”.  This is true but if you truly documented every single thing you did in a day, it would take you another whole day!  So the goal is to really prioritize your documentation.  What is a priority?: 1.  Assessment – A thorough assessment is the value nurses bring to patient care. It drives treatment, demonstrates patient improvements and identifies deterioration.  A thorough documentation of patient specific assessments is where you need to be spending most of your time.   2.  Follow-up issues – Any time you indicate a problem, it is critical that you document proper follow-up.  For example, you note that a patient is short of breath, pulse ox of 90%, resp rate of 24 and has crackles 1/2 up bilaterally.  You contact physician who gives you an order for Lasix 20mg IV and increases oxygen to 4 liters.  It is critical that you document (lung sounds, resp rate, pulse ox, urine output, etc) your follow-up assessment until you indicate that the patient is back to baseline.  Time saving tips for documentation: 1.  Chart in the room – Either with a computer on wheels or a paper chart,...

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Structural Empowerment

Structural Empowerment Structural empowerment is a term that refers factors in the environment that promote your ability to be effective:  Opportunity, information, resources and support. Knowing how challenging it can be to keep up with the demands of your role, find ways to identify each of these factors while at work.  Let’s start with support.  At the beginning of each shift, grab yourself a partner – another nurse that can partner with you throughout your shift when you both need extra help.  You can cover each other for breaks and lunch, help each other out when your assignment gets crazy, and tap into each others strengths.  For example, when I worked on a cardiac step-down unit, we drew our own blood gases and inserted IVs.  I was really, really good at both.  However, I always (and still do) struggled with chest tubes.  So, anytime a patient would need an IV or blood gases drawn, I would do them (helped my colleagues and it was better – more effecient for the patients).  And if I had a patient with a chest tube, one of the other nurses (it was her strength) would come in with me and do my assessment with me.  Win-win. How can you start to incorporate this type of partnerships with the nurses on your unit?  What can you differently that will move you towards structural...

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Celebrating Nursing

You just never know when paths will cross and you will meet an amazing human.  I met Judy Starr in a classroom at Waynesburg University located in Western Pennsylvania.  Judy was taking a Community Nursing course as part of her RN-BSN program.  I was her instructor.  A requirement of the course was to complete a service project in the community.  Judy and her husband decided to meet with mission leaders at a Spanish immersion school and were matched with Leonardo’s Home of Hope – an orphanage in Honduras.  They were looking for nurses and physicians to support their mission trips and as a couple, they decided to go. They joined the trip in Aug 2008 for the medical mission purpose, and met the children of the orphanage.  Being a pediatric nurse, Judy was more interested in the children of the orphanage than anything else. Their pure joy and happiness to meet new people came through their smiles.  Although she had met the requirement of the course, Judy and her husband continued their support of the orphanage.  The trips reinforced her desire to stay a ‘hands on’ nurse. She enjoys the interaction with patients and families (albeit not always pleasant) but part of bedside nursing. Judy’s mission experience has prompted her to pursue travel nursing as another way to spread her competence, care and compassion. The connection with the children...

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Today’s healthcare environment is very different from when I graduated over 20 years ago.  Back then we had time to do the little things that made us feel human – pm care, real patient education, and even an occasional “hanging out” with patients and their families. Now, nurses find themselves in a whirlwind of increasing demands, technology and patient acuity.  Not only is being competent in delegation more important than ever – it’s a matter of survival.  Yet it is a skill that most nursing professionals identify as our biggest weakness. So, what are we going to do about it?  We need to start learning the “skill” of delegation.  We will start looking at delegation and begin the steps to mastering this critical skill.  I invite you to share any tips that work for you – chances are, they will work for others. Delegating to nursing assistants:  Many nurses find it difficult to delegate to nursing assistants that are older than them or have been there for a longer period of time.  I know some of them can be intimidating but delegation is a skill that you need to master.  Most new graduate nurses and even seasoned ones struggle with this skill so you’re not alone. Here’s a tip:  Avoid using the phrase, “Can you do me a favor”.  It implies that it really isn’t their job and that they are just...

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Joining Professional Nursing Organizations

Greetings One of the first steps to becoming serious about your role as a professional nurse is to join a professional nursing organization. Nursing organizations can provide you with the resources you need to advance your skills and knowledge in your specialty. They also provide you with the ability to network with other nurses that are passionate about their profession! Check out my website:  www.rtconnections.com for a list of professional nursing organizations.  If you’re not sure which one to join…just ask me!!  I can help you to figure it out. Take care and stay connected...

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January Communication Workshop

Communication Workshop for Nursing Professionals Transforming your practice through skilled and deliberate communication There are currently more than 600,000 physicians in the United States but over 3.1 million nurses.  However, nurses have earned the dubious title of “the silent majority”.  Now, more than ever, nurses have the ability to impact the direction of their practice and the future of their profession.  Change is inevitable and to ensure the voice of nursing is heard, it is crucial that nurses develop the communication skills necessary to influence decisions.  Whether a nursing student, bedside nurse, a nurse manager or educator this communication workshop will provide nurses with the communication skills they need to transform their practice. Workshop objectives: Recognize communication styles and how they impact the work environment Resolve conflict and embrace differences – tips and strategies Communicate successfully across generations Improve verbal and non-verbal communication among individuals and groups Advance professional practice – making a good first impression, building relationships and creating professional portfolios Jan 22, 2011 – Pittsburgh PA Robert Morris University8:00 AM – 3:30...

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Renee Thompson
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