Are you struggling to understand what’s needed when you’re documenting care? Do you feel overwhelmed with documentation and want someone to clear it up? Well, you’re in luck. Because we’ll guide you through the <b>Top 5 Things You Should Be Documenting</b>. Show up with questions ready!
Cornell Note-Taking System Instructions:
- Record: During the lecture, use the note-taking column to record the lecture using telegraphic sentences.
- Questions: As soon after class as possible, formulate questions based onthe notes in the right-hand column. Writing questions helps to clarifymeanings, reveal relationships, establish continuity, and strengthenmemory. Also, the writing of questions sets up a perfect stage for exam-studying later.
- Recite: Cover the note-taking column with a sheet of paper. Then, looking at the questions or cue-words in the question and cue column only, say aloud, in your own words, the answers to the questions, facts, or ideas indicated by the cue-words.
- Reflect: Reflect on the material by asking yourself questions, for example: “What’s the significance of these facts? What principle are they based on? How can I apply them? How do they fit in with what I already know? What’s beyond them?
- Review: Spend at least ten minutes every week reviewing all your previous notes. If you do, you’ll retain a great deal for current use, as well as, for the exam.
For more information, visit www.nursing.com/cornell
All right, give everybody just a second. I know that Nicole is finished or is finishing her session, so I’m maybe got some people coming in. I want to give this just a second. Let me see if I can do something quick.
while we are reading.
Let’s see. Please look at that Mat.
Cool. All right, so let everybody come on just one second. Um, if you can hear me, uh, just drop your name in the chat. Just somebody know where you’re from. I want to see if it’s here today before we get into all of this.
let me see if she still has one going on. It is Friday afternoon. Everybody is ready for the weekend. Let’s see what’s going on. Come on a couple more. I know Nicole is finishing up so overtly. Yeah, honestly she’s done. No wait for a couple more people to jump on.
This is [inaudible].
Let’s see. All right.
Yeah, she’s still currently live. So, all right, we’ll start with a small session and then we’ll come back to it. Oh, here come more people. Cool. So, um, I’ll repeat this question in just a few minutes, but how many of you actually have a documentation course? If you have a documentation, of course, let me know in the chat. Uh, cause I think it’s really important to get a good understanding of where everybody’s at starting at a baseline. Um, if you have a documentation course, what do they tell you? Bridget? Uh, in the Canada. Victoria, British Columbia. Hope it’s awesome up there. Hope the weather, not a documentation course. Of course not. Um, so they tell you that you need to do these things and you need to provide this care for this patient. And then they tell you to do what after you do it.
The struggle is real, I feel. Yeah. So they’d say the document, right? Oh, here, come on people. Cool. So you’re supposed to document everything. It’s just like what, you know, your instructor say, well what do you need enough for the test? Everything. Well, no, we’re not going to do that today. They were talking about like the top five things that you need to know about documentation and why you needed another one. We’ll kind of go in the ins and outs in them. So EHR plus, oh, you’re doing both. Oh my goodness. Bridget says she’s doing an electronic health record plus paper, documenting, losing your mind. Do you, I feel you, um, what are they having you document that’s on paper?
it should be very little. If you have an electronic health record.
For graphics, Heparin, just boom, gross, gross. Those, those insulin drips and those Hepburn drifts. What a pain. Yeah, you can’t, they’re challenging. Right. So I’m going to talk, I’m going to speak to the one that I’m most familiar with today when we’re talking about documentation. Electronic health record actually can move this up just a little bit. Apparently I’m really close. Um, there’s not going to be a lot on the screen. Just some kind of, some big key points and I’m going to do a lot more talking. Um, feel free to ask questions throughout the session. Every session is going to be a little bit different. Um, and we try to cater to everybody that comes in. Um, and I, I think kind of the vibe that every tutor gives in their presentation is going to be important. Um, so I really think that, uh, based on this session, we really can get an I a better idea of, um, of what, uh, what we’re actually going forward today is going to be a lot more of that going back and forth and, and just kinda talking through, uh, what you guys need to know for documentation.
So we talked about documentation. Uh, I’m going to give you kind of like the top five, my top five tips. I love documentation. Um, I spent, uh, quite a few years before it was a nurse, as a veterinary technician and I’ve seen all sorts of different documentation there. I had, uh, I can’t tell you how many notes that are and how many charts that I had, whereas it’s handwriting everything. At one point I was doing like an invoice ledger. It was an entire nightmare. So I appreciate electronic health records. Um, and during my clinicals they were in electronic health record and, uh, they were in a paper and then they switched to the HR. Um, part of my master’s, I wrote a big paper on EHR and the benefits of it. So there’s a lot of things, there’s a lot of good benefits. Um, but ness, the problem that there seems to be a disconnected, he, that you guys need to try everything but you don’t know where to chart or how to chart it. So we’re going to go over some of those key tips today. So the first one is avoid avoiding double documentation. And I’m speaking to epic. Epic was the one that I was most familiar with. I know Cerner does this. I know some, I’m trying to think of a couple of other ones that, that do um, flowcharts. And so a flow chart, it looks like a big spreadsheet and you’ll have like a list of things. Um, so tell me in the chat real quick why you think avoiding double documentation is really important.
Matrix. I’ve heard of Matrix, I have heard of Matrix. Um, but tell me why do you guys think that double documentation avoiding it is, um, is important. Cause this will also help me to understand if I need to explain what double documentation is repetitive, not efficient, more errors. The one more thing that I’m looking for could be dangerous. Theoretically it could be dangerous. Sarah says it could be dangerous. That’s a possibility. But there’s one more thing that I’m looking for. Could chart different things. It looks like things are done twice potentially. Um, Bridget, I want you to elaborate. I want you to think just a little bit beyond that so you could chart different things. So let’s say a patient has something,
for instance, let’s say like this, your Maher says, so there’s Sam, Samuel says discrepancies. So let’s say you’re Mars says that you’re supposed to give me mall. I love the, I love using the term me mall. Um, you give me mom, she’s in 94 year old patient on the unit and she has a dose of 0.2 of dilaudid for pain. And you go into your, your, uh, you go into the mar or you go into your patient’s room and you do your six patient rights, you scan it, you give out the 0.2, you give it to me, Ma, she has an adverse reaction.
But in your nursing note, you actually put that you gave one milligram.
So if that’s the case, what let’s say, let’s say Mimo dies, okay, I’m going really deep fear family gets upset. What could potentially happen? Don’t think nursing. Think a little bit different, essentially, which does what?
get sued, right? There’s a, there’s a, there’s a level of liability and you guys are working really, really hard. You guys are in the, in here grinding every day. You are hustling, getting stuff done, and you’re spending your time in the academy and you’re spending the time of the textbook. You’re spending time at clinicals, you’re working really, really hard. Um, I will say this as a caveat. Um, and it’s just one way to think about the state board. The state board is not here to issue out licenses. The board is there to take them away. They’re there to regulate that they’re regulate unsafe practice. Um, it’s a privilege to be a nurse. It’s not right. Uh, we all work really hard. We all go through the same process. We all do the in clinics. And to have something as simple as double documentation to get all that messed up, we want to avoid it.
So here’s the way you look at. So when I talk about epic, epic really looks like, um, flow sheets. So, and I think next time I do this, uh, I’m going to try and bring some examples of what I’m talking about, but think about excel. So Excel, it looks like a big spreadsheet. And so like in this first column it’ll say like, these are times, right? So I have these time shirts in here you’ll say physical exam, head, eyes, nose and throat, Pete. And then you’ll have like a time and a dropped mountain time. And I dropped me on time and I dropped me. I’m tired of drama. So you do your whole physical exam in this tab, your whole physical exam, and then your next tab, you have lines, drains and airways talked about every line you hop, you talk about every drain you have.
You talk about everything. Next Tab, you have pain in your pain assessment and eight o’clock, you do your paid assessment. Me, most paint is zero. Cool. Um, we talk about what scale you use. It goes through the entire thing. Then you have a plan of care. Then you have your patient education and then you have um, sign off, right? You have all these tabs, all these floaters. So in your nursing narrative, you go and you chart something. What you should chart in that nursing narrative, and I’ll, we’ll talk about the narrative in a minute, is that things that you can’t cover in the flow sheets, if you document it in one place, if it’s documented, then you should document it anywhere else and it sets up a potential liability. Um, and if your unit or your hospital or your facility or wherever you work requires you to double document, you need to be having conversations.
You need to say, you need to explain why, because you have a degree of like, I’m not gonna tell you to start a revolution, right? This is not, you’re not going to revolt against, um, against the man. Right? And the thing that you want to do is you want to establish a safe means of practicing. And if they say you have to chart your flow chart and you have to chart in your narrative, your, your, um, assessment, then it’s not efficient. It could lead to errors. Um, it can also lead to discrepancy and liability. So I would bet not many facilities would do that, but just pay attention to what your facility says in terms of what the minimum type of documentation is. Um, but you, oh, you want to avoid double documentation at all costs. So that Kinda leads me to my next point, which we’ll make a little bit more sense, which is talking about painting a picture.
So your nursing narrative, your nursing narrative and the stuff that you typed should paint a picture of the things that can happen in the flow sheet. So, um, there’s a, an epic, there’s a critical lab tab, right? So you lab calls, there’s a critical lab. Um, you walk over to your critical lab, you call your, your provider. Hey, I got this critical Traponin it’s 0.1, whatever. Um, it’s been 0.1 the entire day. You know, it just happens. You’re doing every eight hour, uh, tropes. Um, you call it provider, you document it, right? What you don’t need to do is go in and say, oh, hey, at this time I haven’t documented the entire documentation. Or like a, you wouldn’t say MD Smith called critical lab report at 0.1. It’s already somewhere else. You don’t need to do that, which is avoiding the double documentation. Let’s say meemaw code’s right.
You give her the, you give her the 0.2 she codes. Then what you do is in that you say, Andy Smith notified patient unresponsive, uh, code initiated c code sheet for details. That is all you put in there. Unless something specific happens, you want to try to paint a picture of everything that happened. Because let’s say in the code sheet, it’ll code sheet. I say this often, let me type it in here because last time I did this code sheet, that’s what it is. So code sheet is literally in the crash cart. It’s a sheet and everybody can document specifically when everything happens. Times initials, providers or signatures that have to go on it. But what happens is that code sheet will, um, will show everything that you’re doing and there’s going to be a nurse that’s going to be just a recorder and that’s all they do is they record that stuff.
Um, in doing that, I don’t need to write everything that’s on the coach sheet into the narrative because even though there’s no place in the flow chart for it, it’s documented somewhere. All you have to do to make sure that that piece of paper is on the chart and make sure it’s in there. When you do handoff, that’s your responsibility. Um, so what you want to do with the documentation is you want to paint a picture of the things that are not happening in B Smith called, uh, a patient, patient unresponsive. Um, typically, well I probably what I would do is do it, write it down and other things. The other thing is you want to write down things in the order they happen. Um, you want to say things like patient unresponsive, you write the time, a lot of them will timestamp it. So you’ll say like time, date, um, patient, unresponsive, patient stimulated, no response code initiated in the Smith, notified by RN John and like just write things down in order.
Um, that way at least in the narrative, it looks like you did it if you, and the thing is you’re not going to be able to do this like all at the same time. So just think about it when you’re writing your note out, how, how things progressed that way at least, um, in review or audit or litigation, you have a way of backing yourself up because in theory, any sort of prosecuting attorney, I’m a true crime buff, lecture, crime. But they would say, oh, well why did you like this? And then you have to say, well, I didn’t do it in that order. It just all happened at the same time. Um, so try to be as meticulous in those situations when it happens, but for the most part, that’s what you want to do with your nursing narrative. So let’s talk about the next one. I want you to finish this sentence. If you didn’t chart it
it didn’t happen. So,
when I say that, I also mean that just because your timestamps not correct that it didn’t happen. What you need to do is always make sure at the end of that, at the beginning of the day and at the end of the day, start a routine when you’re doing these things. I think I covered this. Maybe another slide. Be Consistent when you chart, always chart the same thing in a certain way and always make sure that you chart everything as possible. We use something called a time tape, which is basically a piece of paper that was folded in half. And on the front half of it would be our, um, our entire report. Patient name, date of birth, code status, allergies, um, medical history, why they’re here, all the systems, line strings. There was a whole thing, flip it over and on the other side was, um, hourly times seven o’clock has report if there’s any clock meds, eight o’clock was assessment.
12 o’clock was a set, like you would write everything down. Then the thing, I always wore cargo pants and that would sit in my right pocket and never put it my left. So anyhow, I grab it, it’s there. I look at it, I always look at my stuff. Um, so always, even if you’re charting it somewhere else, I’m like on your time tape or what have you. Come back and put it in. Always make sure that you’re doing and if you think you’re going to forget about something, you probably will write it down. Okay. So that’s what if you didn’t chart it, you didn’t do it. So always make sure that you’re documenting all of your care cause you want to make sure that you’re always covered. The heel lift and look to look under like a trake document that you did that skin inspected under tracheostomy, skin intact. Um, always be like very a succinct with when you, when you’re talking about a documentation, so we’re talking about documenting, um, Mimo is coding. Um, you, there are two nurses in the room. You’re one of them, but you need to put in the, you need to put in your note, right?
When do you think you should do that? Did you give me some answers when you think maybe me Maz coding, should you stop to go chart after? Totally. Um, if something is life threatening or is it safety risk, you have to address that issue first. You want your patient to be alive and you want them to be safe. Um, as long as you can kind of hit those two marks, then you can go chart. Um, if you are swamped, learn about time management. Um, my goal was to get some of these times, some also some time management. Um, session’s going to kind of figure out some other way. Probably not. Sarah says, probably not.
Exactly. That’s kind of why we have, that’s the, I’d say the person who’s the recorder for those code sheets are really important. Um, that’s whether they’re, your focus should always be the patient and always their page, the others, their safety and always those abcs, airway, breathing and circulation. As long as you’re doing those things. Um, for instance, here’s a, for instance, um, there’s something called the BCMA and the BCMA is, are the bane of my existence. Hate those things to a core because they’re not representative of what we do. And what BCMA stands for Barcode Medication Administration. What it is is it’s a percentage run by management that says, every time you give a medication, you scan the barcode and you scan the patient. Um, and you had to have like a 90% accuracy on it. Um, so what, what happened was I would get called to my manager’s office. You’d say, Hey, we noticed that you gave a bunch of Adavan without, um, like you had like two or three doses of Adavan, um, and your barcode in skin and your BCMA is low. And then I would say, I want you to go, let’s go back,
let’s go to this guy, go back to my narrative and see what was happening with my patient. The patient was seizing repeatedly. We almost lost the airway and as soon as you had to come to bedside, we have to intubate the way to put them on propofol.
All of these things happen. So sorry, I didn’t scan my meds. This is why it’s really important that you do things like painting a picture and uh, sending, have a little bit of, um, have some confidence in your capabilities as a nurse to walk in and say, this is the care that I provided. I’m, I’m happy regardless of the outcome. I did everything I could for my patient and I did everything in the right way because I had that. I’ve had things come back and they were like, why did you do it this way? And I could give them a good example. My patient’s seizing. I don’t care about the fact that it didn’t scan it. I verified my patient rights. I had another nurse to double check. That was kind of my backup. Even though it wasn’t required, it was, hey, I need to give this double check this dose for me.
Hey, how much should we give the Mara was open. I just didn’t happen to scan it. Um, so it wasn’t ever that I circumvented a system. It’s that I just didn’t scan a medication. And what ended up happening was I didn’t compromise, I did not compromise care, uh, to make sure that my charting was complete on an on time per their standards. And they were fine with it. Just know that you have that capability of doing it. Um, my patient got the right dose, the patient did. Okay. Um, so it was never, I’m not, I didn’t just always follow the rules. Right? Being a nurse requires a little bit more of critical thinking. You got to kind of think through those processes. So I want to empower you to make sure that, um, you guys are making sure that we’re taking care of our patients because there are some limitations to, for instance, like think about if you were on a paper, so Bridget can probably, um, feel this a little bit of this pain is that, imagine if you were, um, you’re doing paper documentation and your patient’s seizing are you to do it, write it down, right?
The doses that you gave down and when you fill out your mar or later you’re going to write it down and it’s sign it off. It just so happens that those BC Mays are there for safety reasons. Um, but in the event of critical emergencies, that’s the way it works. I’m sorry, I got a little, I got a little soapboxy for a second. So the last one, I’ve talked about this a minute ago. Set a routine when you get report, when you give report, when you document, here’s what happened. This is the way I would do it. And this just happened to be for me and it worked well. Get report right. Everything that on my note. Right. And then in the nursing narrative I’d start there. I’d say, um, well first thing I would do is there is a tab for sign off, sign off, sign on, sign off report report given to receive that by this nurse.
Go ahead. Understand narrative 7.7 we had like these things called a smart scripts and so you would enter like a, a particular code and it would prompt, it would auto fill this thing, but it was always like seven o’clock report received, patient turns get inspected. Um, all lines, airways verify, safety check completed. Cool. Then eight o’clock, eight o’clock, I’d roll in after I’m done with all my care, everything I needed to do and I would start when I started documentation, always start with the first tab, do everything I need to on the first tab, which was a like assessment lane strains Arrow is this next one was pain, totally going to do all my pain stuff. Then the next one was like, uh, let’s say it was patient, uh, uh, a plan of care, right? So they’re my care plans. Just make sure they’re all verified and make any adjustments as they need to.
Uh, patient education. If I ever educated the patient, I’d go and make sure that those are all verified. And so every single time I did that, um, every time I would go through the Marv, I would do the same thing, set a routine and be consistent with it. You’re gonna have to find things that help you, um, find things that hurt you. If you realize you’re like, man, that sucked. What did I do different? Why did it take me so long to document? Was it just a heavy patient? Was it a, uh, what was my patient load? Just too heavy in general. Whether shortcuts that I could have made in terms of, instead of maybe I took, maybe I did this one thing and then documented and did this one thing and then document. Maybe it needs to be that I need to change how I’m doing things.
Then I’ll speed up your efficiency. Then I double document, did I go spend time doing this? I’ve worked with so many nurses that drove me nuts, drove me absolutely bonkers. They would go and they would get report and then they would immediately, after they fill out their, they’re like, um, assessment tab. They’ll go to the nursing narrative and then document their entire assessment. And I’ll tell you, one of my friends would probably like, like I love you a lot. Like you are creating more and these notes are long. You’re creating more work for yourself and you’re also creating this potential for discrepancy. If your patient has a problem and these things don’t match, it’s going to be people are gonna wonder what happened. Like you could theoretically not only misrepresented the care you gave, but you could potentially set yourself up for litigation and that you’re falsely documented.
Did you actually give that medication or did you not give it? Did you give enough of the dose? What happened after? There’s all of these things that come into play. So that’s why like all of these five points are so important. So I want to open it up for questions. I want to answer whatever documentation questions you have. Um, I know that this was, um, you know, it’s Kinda hard to, to be very specific, but I can help you with hypothetical’s. Um, I can’t tell you, you know, if I was running an epic, hey this is how you do epic. Cool. I could probably run you through that. But like Matrix, I think Danny does it. Danny’s, yeah, no, I’m good. Back Up. Um, yeah, Danny, Danny said she’s got matrix. No clue. We could probably figure it out together. But the thing is is no, your EMR, your EHR, whatever charting system you have, figure out that routines, set that routine up. Go through that process. That way you’re not, I feel, I felt like there were some days I, you know, I’m getting double shifts and then spent another hour of documenting cause it was such a pain. So I totally feel you. All right. Any tips,
any tips for documenting things you’re giving for the first time? Uh, so Bridget, Bridget, second part is, for example, I gave out even for the first time and had no idea where it’s right. Well Bridgette was, you’re up human in your Mar. That’s kind of weird. I would expect IBM to the Omar cause it’s a medication stat order. Stat orders should never prevent the necessary documentation from happening.
I’m kind of curious as to why I’ll be in, what was the stat order? Um,
I won’t ask. Don’t, don’t, don’t write it in the chat cause I don’t want, I don’t want to get into like HIPAA violations. Um, it doesn’t make for me that does it make sense? However, what I would do is, um, something like, let me see if I can open, we’ll play a game for a second.
I’ve got some time. Um, what I’ll do is I’ll open up, uh, let’s see if I can do this. What I’ll do is I’ll open up like a, a word document and I’ll show you how I would probably write something if that, if that will help you out. Huh? Oh goodness.
um, let’s see.
that’s true. Bridget. I, I’m going to say that that’s tricky. And the reason is, is because it’s a medication. It should have been put in the Mar. Um, was it ever put in the Mar?
Okay. So what eventually was put in the Mar? Okay, so here’s what I would do. This is what I would write. Let me see if I can screencast this.
Oh my goodness. Got So bright. Sorry. The screen is going to try to adjust here in a sec. Bear with me and then Sammy, I’ll come to yours. Okay, cool. So let’s do this.
can I, I’m cool. Here you go. Here we go. Here we go. Let me get giant. Uh, let’s do this.
All right guys, give me one second. This is not something I normally do, so I want to try to make this work for you if it helps. Cool. So let me do it this way. I’m going to turn the screen. Let’s get this guy really close. Deep Do-do cast. So Venus. All right, cool. Bear with me. Let’s make this even bigger. What? 50 cool. Excellent, cool. Can y’all see that? Perfect. Okay, so you said I’m even right. So what I do is first off time, I don’t even know what day it is. It’s just a day. Oh, it’s is the 21st. Oh my goodness. If I didn’t have auto reminders I would lose my mind. Um, 1500, whatever the time of day it was. Um, stat. I just, what I would say is that order received for albumin, albumin given per Maher C R for details.
that’s what I would say. Cool. I wouldn’t say anything other than that, especially if you have, yeah. So with your, um, with these types of, uh, document documentations, you want to keep it short and sweet. Okay, cool. I received a stat order. Cool. They can go back into the orders and look and see what the order was. Cool. I’ve even given per mar, you were saying that you are following exactly what that Marr says and then you say, Hey, you know what? I gave it per the Mar. See the Mar. If you have questions about it, I don’t see my nursing note cause I’m not gonna tell you what it, because then you get into all the nuances of getting an a, I’m like a drug. So here, here’s one check. I’ll show you a one. Okay. Uh, I know you guys always ask about these blood transfusion order received, right? Everybody loves these blood transfusions. Okay. I got an order for it type and screen completed shows that you did. You sent your lines out. They can find those m x question. All right, type of screen completed then what I would say is this, a RN rigid. Bridget, we’re gonna use you today. Make sure I spell your name right. I’m present at that sign for, oops. I can’t type
to RN checkoff.
see blood transfusion flow sheet for there’s a delay. So give me one second. I’m trying to get this in. I can’t type
there’s an s in here. Cool. Cool. There you go. I got an order. I completed my pre-op or my pretransfusion labs. I show that there’s a second iron at the bedside for the to Orange checkoff. And guess what? I’m going to send you to that flow sheet cause I’m not about to start documenting all of that nonsense in my nurse’s narrative for the next four hours. I will lose my damn mind. No Way am I doing that. That’s exactly what I’m putting in there. Okay, so I want to come back to the Samuels question. This is somewhat consolidated. When there’s an incident fall. We assess the patient check for injuries, tell chargers. Um, but we don’t target the fund new. No, no, no. Do not. Okay. So I’m going to reread this somewhat related. When there is an incident, we assessed the patient check for injuries. Tell the church nurse then fill out the incident report. But we don’t chart the fall in the EHR. Correct? You never want to. This is another key thing I don’t want to mention. You never want to admit guilt, um, to anything in, um, in your medical record, right? Or anything. You mean nursing narrative. So you make it very subjective.
so what, so what did you do?
Danny says when you’re trying to observe on floor, um, patient observed sitting at floor on bedside patient c’est
let’s say they had a cut on their arm from the fall, like from the bed, a two centimeter laceration to left forearm.
Spell that wrong.
Pressure Bandage applied in B Smith
notified at bedside. Cool. Right.
I didn’t say it fell. I didn’t say I observed them sitting on the floor.
So we chart that we found them on the floor. We it. So you didn’t see them fall like the thing is is like, so if they, so let’s say you did see them fall, right? So this is what I would chart
so let’s say you’re standing by the patient. I’m also not going to tell you to falsely document, but I will say this. Okay, let’s say you’re walking with me more, right? And Mall starts to get a little woozy and she goes down and you assist her to the floor. Patient complains of dizzy. Oh, that’s crazy. Dizziness. Um, and
um, I want to say this
became unstable, assisted to floor.
Cool. Let’s say she still cut her arm on the way down that complainant dizziness and became all, I would actually probably take out the unstable, I’d actually probably documents something like, um, here you go. Do that. [inaudible] the other thing you want to do with your nursing narrative is remove ambiguity. So if I said unstable, they’re like, what does that unstable me? Well, look, I don’t need to do that. I need to say if they said, hey, I feel like, um, patient states feel like going to tip over. Cool. Whatever the patient says. That’s what you put in quotes. But patient complaints, indigenous patients, we’re going to tip over, assisted to the floor, patient assessed to [inaudible], blah, blah, blah, blah, blah, blah, blah. Cool. I didn’t, she may have fallen or she started to fall and you caught her on the way down. That’s all up for interpretation. What you need to put in your narrative is what actually happened and be very succinct with it.
Does that make sense? Cool. Any others?
This is my bread and butter right here. I love this stuff.
Health, health status. Can you elaborate? Bridget says, what about health status notes? Can you elaborate on that? It seems like people want for health status now. Hmm? Can you give me an example?
Like once per shift. Oh, okay. Um, so
here we’ll just do this. We’ll do this. We’ll say it like this. Oh wait a hundred.
Let’s say a patient. Um, oh, this is what I put. Head to toe assessment, completed safety check completed medications. Given per mar patients resting comfortably. It’s eight o’clock in the morning. They’re tired. Okay, cool. That’s my eight o’clock assessment. Look at that. I didn’t need to put anything else because my entire blah blah, blah is all in there. Okay. So 10 o’clock rolls around, you’re going to get meds right?
Medication’s given per Mar. No changes to patients.
Besting Comfort with eyes closed.
Cool. There’s my update. I’m sorry, my, uh, my laptops in the light here.
there you go. That’s all I would do differently. You ready to go up there? Yeah, we’re talking about documentation.
I definitely wouldn’t be able to get ahold of shirt eight and 10. Oh yeah. Cause you have some sort of weird LTC and only document on the ABC status changes in behaviors. Oh, there you go. I wouldn’t do anything different, but you want to keep your documentation and your narrative really short and sweet. There’s no reason cause this, all of this is somewhere else. So. All right guys, I’m gonna wrap it up. A lot of fun today. So, um, yeah, keep your questions coming in. We’re going to keep the Sydney sessions coming. And then, uh, one more thing real quick, like we do all the time. Just like to get a little feedback. Hold on, let me get it. Or you get that
[inaudible] bear with me one sec. You’re welcome. I hope that I was helpful. I know that some of this stuff, like they don’t ever teach you to do this stuff right? It’s, Oh, just document. Oh, what the hell am I supposed to document? Yeah, we’re not doing that. So here we go. Like we do all the time. Hit that link up. Give me some feedback. Let me know what you think. Um, we’re always trying to make these better for sure. Yeah, I like doing documentation. It seems like people are getting a lot. Um, this was something new I tried today. So if it works well, I may start doing it a little bit more so we can type through kind of how you document and what this actually means in terms of like the narrative, cause this is where people, a lot of people struggle. So. All right guys. Um, I’m gonna peace out for the weekend and, uh, next week we got a lot more, uh, more tutoring sessions coming up. Hit those up. Uh, John, be back Tuesday for, uh, is Tuesday. Um, test taking session. A lot of fun there. So, all right guys. Well, it’s been a lot of fun. Um, peace out. Go out and be your best self this weekend. And as always, happy nursing.