Tips for Great Nursing Documentation

How to write a nursing progress note

1. Gather subjective evidence.
2. Record objective information.
3. Record your assessment.
4. Detail a care plan.
5. Include your interventions.
6. Ask for directions.
7. Be objective.
8. Add details later.

The Dos & Don’ts of Documentation

• DON’T copy information. Write each transport as if this is the first time you have seen or treated this patient.
• DON’T use vague terms.
• DON’T use P.U.T.S.
• DO support medical necessity.
• DO be specific.
• DO be truthful.
• DO document treatment results.

Best practices for writing documentation:

1. Include A README file that contains.
2. Allow issue tracker for others.
3. Write an API documentation.
4. Document your code.
5. Apply coding conventions, such as file organization, comments, naming conventions, programming practices, etc.
6. Include information for contributors.

Documentation process standards define the process used to produce documents (example here). This means that you set out the procedures involved in document development and the software tools used for document production. Document process quality standards must be flexible and able to cope with all types of documents.

1. Be Accurate. Write down information accurately in real-time.
2. Avoid Late Entries.
3. Prioritize Legibility.
4. Use the Right Tools.
5. Follow Policy on Abbreviations.
6. Document Physician Consultations.
7. Chart the Symptom and the Treatment.
8. Avoid Opinions and Hearsay.

Documentation is the written and legal recording of the interventions that concern the patient and it includes a sequence of processes. Documentation is established with the personal record of the patient, which constitutes a base of information on the situation of his health.

Enhance your documentation practices

1. Chart in the correct record.
2. Chart promptly.
3. Be accurate, objective, and complete.
4. Track test results and consultation reports.
5. Avoid repetitive copying and pasting.
6. Use approved abbreviations.
7. Include patient communication.
8. Record instances of non-adherence.

Nursing documentation should, but often does not show the rational and critical thinking behind clinical decisions and interventions, while providing written evidence of the progress of the patient.

1 NZNO, HWNZ Post Graduate Coordinators Group, MidCentral Health Nurse Governance Council, Palmerston North, New Zealand. The quality of nursing documentation is an important issue for nurses both nationally and internationally.

However many nurses still experience barriers to maintaining accurate and legally prudent documentation. A review of nursing documentation of patient care and progress towards achieving outcome goals in our organisation identified a lack of clear and easy to follow information about the patient’s progress.