Document What You Do Checklist

The entries you make in the medical record should show you took appropriate actions in response to the patient’s condition. Record as close to the timing of the events as possible otherwise you may not remember key points, times, or persons that are important to record.  Record “real-time” when documenting interventions.  Real-time entries may avoid the appearance that a delay occurred in your response to significant findings.  Always follow interventions with entries that show how the patient responded indicating the effectiveness of the intervention because not all interventions are effective as you know. 

Referrals are often necessary for ongoing care and treatment.  When referrals involve other providers, such as home care or social services, include interdisciplinary meetings discussions and patient current plan of care and discharge planning.

Documentation Checklist 

Essential Documentation Goals

- Accurately describe the patient’s condition and progress.
- Communicate clearly.
- Satisfy legal requirements.

Accurately describe the patient’s condition and progress 

• List initial assessment data. 
• Identify potential and actual problems on the plan of care. 
• Describe specifically procedures, treatments, and medications administered. 
• Describe the patient’s responses to procedures, treatments, and medications. 
• Outline patient teaching by including topics covered and evaluation of the patients understanding using teach-back method or teach-to-goal. 
• List nursing actions; interventions. 
• Name individuals you consulted with regarding the patient’s condition. 

Communicate clearly

• Record dates and exact times for assessments, interventions, and other events. 
• State the facts in a concise manner. 
• Use quotation when describing symptoms a patient tells you; avoid interpreting what they say. 
• Describe only what you have seen, heard, touched, or smelled. “First-hand knowledge”. A
• Avoid recording assumptions and personal opinions. 
• Use only standardized abbreviations. 
• Spell correctly. Check the spell check! 
• All handwritten entries must be legible. 

Satisfy legal requirements

• Make corrections according to your facility policy for documentation. 
• Be accurate and truthful. 
• Avoid omissions, blank spaces, or unused spaces. 
• Follow your facility policy for documentation on forms.
• Record ALL communications with those who have the authority to give you orders. 
• List all nursing assessment findings and actions taken. 
• Never refer to an incident report or other documents that are not a part of the medical record. 
• Sign your entries: handwritten or electronic as appropriate. 

What difficulties do you have with the EMR?

Document What You Assess and What You Are Told

Document What You Assess

The first encounter with a patient usually includes obtaining a health history interview when you gather information about the patient’s current symptoms and past health status, previous medical treatments, and responses to treatments or procedures.  This information is the basis for the formulation of the plan of care and the devising a teaching plan appropriate to the patient’s health literacy level.  The primary source for this information is the patient, however when the patient is not able to provide reliable information or is incapacitated, the next best source may be immediate family members and the previous medical chart if the patient if available.  If you are able to speak with the patient, use quotations to describe the patient’s symptoms, avoid interpreting what they say.  This helps to clearly differentiate yours words from the patient’s words. 

The first encounter with a patient usually includes obtaining a health history interview when you gather information about the patient’s current symptoms and past health status, previous medical treatments, and responses to treatments or procedures.  This information is the basis for the formulation of the plan of care and the devising a teaching plan appropriate to the patient’s health literacy level.  The primary source for this information is the patient, however when the patient is not able to provide reliable information or is incapacitated, the next best source may be immediate family members and the previous medical chart if the patient if available.  If you are able to speak with the patient, use quotations to describe the patient’s symptoms, avoid interpreting what they say.  This helps to clearly differentiate yours words from the patient’s words.  

The information you collect from performing your physical assessment includes vital sign measurements, inspection, palpation, percussion and auscultation.  Abnormal findings should be described in detail as they relate to the patient’s current condition.  It is also important to record the patient’s denial of symptoms that would be of concern as related to the patient’s current diagnosis or condition, for example, a diagnosis of myocardial infarction and denial of symptoms of chest pain.  These are what could be called pertinent negatives. 

Use objective terms and be specific to avoid making judgments of assessment data.  For example, “The patient’s urine output was only 90 ml,” this may suggest you think the urine output was too low.  Quantify your findings whenever you can by specifying numbers, ranges, degrees of elevation, temperature of heating or cooling blanket, or aqua K pads etc.  Phrases like “a little”, “a lot”, "appears", "fairly well", etc. leave ample room for wide interpretation, so avoid using them. 

Describe first-hand knowledge which means what you see, feel, smell, and hear during your assessment.  Avoid documenting your interpretation of patient behavior.  For example, document “Sarah was crying during the assessment” instead of “Sarah was crying during the assessment because she is depressed.”

Document What the Patient Tells You

The first encounter with a patient usually includes obtaining a health history interview when you gather information about the patient’s current symptoms and past health status, previous medical treatments, and responses to treatments or procedures. The information should be verified as understood so misunderstandings are less likely to occur.  This information is the basis for the formulation of the plan of care and the devising a teaching plan appropriate to the patient’s health literacy level. The primary source for this information is the patient, however when the patient is not able to provide reliable information or is incapacitated, the next best source may be immediate family members and the previous medical chart if the patient if available. If you are able to speak with the patient, use quotations to describe the patient’s symptoms, avoid interpreting what they say. This helps to clearly differentiate yours words from the patient’s words. 

Organize Your Entries

It is not always easy to make documentation a priority.  Time constraints may lead you to think that other patient care activities are more important, particularly in a crisis situation.  Often documentation is pushed to the bottom of the list of priorities.  To help prevent documentation from becoming a burden, organize patient care information into categories. 

If  you have other areas that work for you, please share them!

What the patient tells you.	This is information you obtain directly from the patient or from the patient’s representative if the patient is incapacitated in some way.
What you assess.	This is the information you collect from performing your physical assessment.  It includes vital sign measurements and inspection, palpation, percussion and auscultation.
What actions you take in response to your assessment.	The interventions you perform. Interventions may be dependent, interdependent, or independent.
The patient’s response to your interventions.	The patient’s response may be favorable or may be an abnormal or deterioration in response to treatment or therapy, which would then require a modification in the plan of care.
What you teach your patient / family.	The health information or instructions you give a patient or their family.  Health information is expected to be provided in a manner that is meaningful and useful to patients i.e. health literacy factors.

Problematic Areas Where Gaps in Documentation Occur

Abnormal vital signs.  A significant deviation from what is considered to the patient’s normal requires an entry detailing what is being done about it.  For example, deviations may be fever, elevated BP, or slow respiratory rate.  If your response is to monitor the patient more closely, then write that in the medical record followed by the response of the patient improving or deteriorating or condition is labile.  If your response is to consult with the physician, record the time you placed the call or initiated the page, the physician’s response and orders received were carried out.  Sometimes you may not be able to reach the physician initially.  In this case, note the time you received the return call; the time you called for a second attempt; or the time you contacted someone else (perhaps initiating the chain of command).

When a patient codes.  Unexpected bad outcomes are frequently the motivation for family member initiating a lawsuit.  The plaintiff’s attorney will more than likely argue that monitoring of the patient was inadequate and the interventions were not timely or just too late.  Documenting what happened during a code or other emergency situation is crucial, yet these situations are precisely when entries in the medical records are incomplete or short creating gaps in the story line.  Avoid these gaps by using the code sheets provided by your facility; designate a scribe to assure the documentation is kept current during the crisis.  Following the emergency or crisis event, check the entries for completeness.  Include the disposition of the patient following the resuscitative efforts:  to the ICU, to the OR.

A patient is transferred.  Regardless whether a patient moves from a high level of acuity to a lower level of acuity or vice versa, or even from one medical floor to another of the same acuity level, a patient assessment is warranted by the receiving nurse.  It is imperative the condition of the patient is recorded upon arrival to the floor and when you assumed care.  This is also true when you are transferred the care of the patient to another nurse, the condition of the patient must be recorded indicating what the patient was last like while under your care. 

Have you discovered areas where you have found gaps in the ongoing care of patients?  There are many areas that I have not expanded on.  Invite me to expand on your areas of concern to avoid vulnerabilities.

The Medical Record: Your Best Defense - 3

The more clear you can make your entries in the medical record, the greater impact it will have on how your care is perceived to be rendered.




For example:

• The medical record is the only written source that displays the events of patient care in chronological order from admission through discharge or death.
• The medical record is the communication tool used by all members of the healthcare team.
• The medical record holds the documents that support insurance coverage (payment) or denial.
• The medical record is the only evidence that represents why patient care decisions were made and on what basis.
• The medical record is the only legal record.
• The medical record is the foundation to evaluate patient outcomes.
• The medical record is the basis for research and education.
• The medical record serves as the objective source for regulatory compliance agencies review for licensing and accreditation. 

The medical record is the only written account of the patient’s stay. 

Make every word count!

The Medical Record: Your Best Defense - 2

Your entries in the medical record are recognized as the evidence of adherence to or deviation from a standard of care provided to a patient. The practice of nursing has become more complex, with the higher acuity, shorter length of stay, electronic medical records, and the increased regulatory compliance requirements including the meaningful use criteria introduced in 2010. Other factors impacting the provision and recording of patient care include: health insurance payors, accreditation organizations, the public as consumers, and legal entities. You must be knowledgeable of the many factors impacting care first, and then, you must be able to satisfy these requirements and expectations, all at once, and with only a limited amount of time. Every entry in the medical record should be made with the regulatory agencies, insurers, state and federal laws, and other professional organizations in mind. It seems daunting, and probably at times, impossible.         

 So, you are probably asking, how close is close? Well, it depends on a couple of things. Let’s think of it is this way first. The higher the level of acuity, the more entries you would expect to be recorded in the record. Why? Because a higher level of acuity requires more frequent observations, more doctors’ orders, more interventions, more frequent follow-up etc. Hence, more frequent entries in the medical record. Now, the opposite would tend to be true as you move to a lower level of acuity. You would expect to have fewer entries in the medical record because of fewer doctors’ orders, fewer interventions, less frequent observations, less frequent follow-up etc. 

Now, let’s consider when you have to make the entries so they are considered as “close” to the timing of the events as possible. This concept will vary, depending upon the acuity of your specialty as previously discussed. I want you to think about when you prepare to make entries in the medical record, what do you do? Do you ever find yourself hesitating, reflecting back, and trying to remember which arm you put that IV in? Have you ever done that? Of course you have. Then with your searching, you conclude that, ah yes, he was by the window. I had to move the over-the-bed table off to the side… yep it was in his right arm. Now, what are you doing? You are talking to yourself! When you are talking to yourself, your facts are fuzzy. You are waiting too long to chart. When you find yourself talking to yourself the next time you go to work, I want you to stop, and evaluate your day at that point and make every effort to document sooner the next day. 

Your goal should be "talk to yourself less and less every day"! If you begin to talk to yourself less and less every day, I guarantee your documentation will have improved, just by doing this one thing.

The Medical Record: Your Best Defense - 1

The entries made by a professional nurse in the patient’s clinical record are recognized as testimony in the courtroom. The complete medical record is identified as evidence in the courtroom. The plaintiff and defense counsel will use any document they wish to help tell their interpretation of the facts of the case to the jury. The nursing entries are valued for the immense patient information they contain. The nurse is the one who is with the patient 24 hours a day, coordinating the care and activities of all disciplines. These functions are multifaceted and can range from diagnostic or clinical testing to therapeutic interventions.

What is the role of documentation in nursing care? It is more than simply writing a note every shift or updating a plan of care at regular, defined intervals. Documentation is written communication between members of the healthcare team. Verbal and nonverbal communication is not captured in the medical record unless it is recorded or documented. If the verbal and nonverbal communications are not recorded, the result is, all is forgotten. The remembering and making entries about what care occurred, including patient responses, and myriad other details, now, take on a whole new meaning with greater importance in the clinical record.

The medical record is your best defense should your care come into question and under scrutiny. If malpractice or negligence is alleged, your entries in the medical record, along with your fellow peers, will most likely determine the outcome of the case. The documentation is heavily relied upon for the very reason as defined above, the documentation, is the evidence of the facts. The medical record is the only source of written communication, for all members of the healthcare team. Each member of the healthcare team contributes patient care according to their specialty and records the care provided including any and all assessments, interventions and outcomes. The actual recording of the events must be recorded as close to the timing of the events as possible.