Book overview
You can be an excellent nurse in the clinical setting and still fail to prove that you are an excellent nurse if your documentation is inadequate.
Having worked in a variety of inpatient and outpatient settings, I understand the obstacles nurses face. There's just not time, nor do nurses have the mental energy to meticulously document every little thing on top of the rest of their to-do list. That's part of why I became passionate about documentation education. It doesn't have to be an overwhelming, endless challenge to chart exhaustively in hopes that you enter enough data into the chart to defend yourself one day.Rather, leveraging the most critical data, knowing how to format notes and exactly what to say, and when to spend five minutes dumping information into the chart can be learned skills that make documentation faster, easier, and less stressful, while doing a better job of defending your actions.
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The Importance of Documentation & Overcoming Obstacles
- Purpose(s) of Documentation
- Defensive Charting
- Obstacles Impacting Quality of Medical Record
- Overcoming Obstacles
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Legal Responsibilities of the Nurse
- Duties of the Nurse
- Nurse Practice Acts
- Duties of the Hospital
- Hospital Policy vs. State Board of Nursing Regulations
- Reasonable Prudence
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Failure to Fulfill (Document) Responsibilities
- Fulfilling Responsibilities vs. Documenting Responsibilities
- What if Responsibilities Aren't Fulfilled?
- Mistakes Happen
- Professional Liability Insurance
- Malpractice
- Medical Negligence
- Acting with Malice
- Fraud
- What Happens When a Nurse is Charged with Malpractice?
- What to Do if You Receive Notification of a Claim
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Common Charting Mistakes & How to Avoid Them
- The Most Common Errors
- Charting By Exception & Charting to Capture Minimal Data
- "But I've Always Charted This Way, and Nothing Bad Has Happened Yet..."
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What You Should Be Charting
- How and What to Chart
- Quick Glance Charting Checklists
- What is a Timely Manner?
- Documenting Assessments
- Sample Focused Assessment Criteria
- Sharing the Responsibility
- Modifying Electronic Data
- Abbreviations
- Standing Orders
- Early Warning Systems Scores & Scales
- Informed Consent
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Special Circumstances
- Paper Charting
- Writing an Incident Report
- Patient Leaving AMA
- Patient Threatening to Sue You
- Identifying Patient Belongings
- Another Member of the Team is Not Documenting Correctly
- Restraints
- Defective Equipment
- Suspected Abuse
- Patient Requesting to View Their EMR on Hospital Computer
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Narrative Notes
- When & How to Write Notes
- One Note or Several Notes?
- Daily Narrative Notes
- Examples of Common Notes Written As-Needed
- How to Title Narrative Notes
- How to Format Notes
- Using Patient Names in Notes
- Length of Notes
- Create a Template
- Tips for Less Stress When Charting
- BONUS: How I Chart on a "Typical" Shift
I'm Andrea, RN-MSN. Perfecting my own documentation and working to find concrete guidelines to share with my fellow nurses has become my passion. As I gained more knowledge and researched the dusty, forgotten corners of the internet for obscure evidence-based practice and case studies, becoming a subject matter expert on nursing documentation lit a spark because sharing this information helps empower nurses to understand exactly what should appear in their patient charts, where, when it should entered, and how it should be phrased.
