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, sit in your patient’s room to document. This allows you to build relationships with your patients and their families, provides you with additional information that you may forget (what arm is the IV or when was the last bowel movement, etc), increases patient satisfaction and SAVES YOU TIME! This may not be possible for all patients, but whenever you can, bring in your computer, do your assessment and document!
2. Timely documentation – After you do your initial comprehensive assessment, document your findings immediately. Most often, this is the most time consuming documentation. This way, if you day gets away from you (as it usually does), you’ve at least entered your most time consuming documentation.
3. Plan time for documenting all of the “other” things you have to do. Whether is related to CORE Measures, rounding, multi-disciplinary collaboration, or plan of care, document these at a predetermined period of time (after your 2pm rounds or after lunch, etc).
I hope these tips help. Please feel free to comment by adding other tips that you have found helpful when tackling the documentation hurdle.
Take care and stay connected!