The Top 5 Things You Need To Know About Documentation
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 Top 5 Things You Should Be Documenting. 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
Yeah. Okay. [inaudible] [inaudible]
oh, warning. Everybody is morning. We’re gonna do some cool stuff today. Talk about documentation. You’ve everybody, just a second. Uh, everybody can hear me. Everybody can see me. Yeah. Perfect. Excellent. Brian and his back zoo is Matt [inaudible] has been here at Google Times. Where’d you some documentation stuff. Oh, Mary’s back. Give everybody just a minute. I know we just opened the sessions that we’re gonna get this one today.
So let’s get it rolling. All right. So start at hand. Start at hand. Show of hands, just type in the chat. How many of you have had, uh, maybe a course on documentation or things that you should know about documentation, um, throughout your nursing programs? Betty has. Interesting.
Who else has, if you have not just say, hey, nope. Not me. [inaudible] nope. It was no, of course, but if someone covered in lectures. All right, cool. So we’re gonna go through some, um, some general documentation guidelines today. So it was like the top five things that, that we usually say to do and what not to do. Um, these are really help guide you through your documentation cause every facility is going to be a little bit different in how they offer or how they want you to document things. Um, and there’s reasons, usually reasons for that. So you usually each have things like, um, the joint commission or um, the CDC, not CDC, CMS. Um, so, uh, the Centers for Medicare and Medicaid services. So, uh, there was a facility that I worked at that was very specific in terms of, um, when pain had to be documented.
Like you had to be, they could have a paint documentation every two hours and then you had to have, um, if a patient’s pain was a certain level, you had to have a pain medication administered and then you had to have a followup. And the way that was documented, it was very specific to the unit was specific to the hospital. Um, and I didn’t see it in other hospitals that are work at. So these are things that just keep in mind as we go through this. So let me share my screen so that you guys can see what I’m talking about. And then we’re going to actually go through some kind of tips and tricks. Um, this is really going to be focused on like the nursing narrative, um, in terms of what you should put in, what you shouldn’t and that kind of stuff. So, let’s see. Let me go share my screen real quick. Bear with me. All right, cool. [inaudible] a let’s do it. All right. Everybody can see my screen. Yeah.
Cool. Starting meditation one on one. This, these are the basics. So let’s get rolling. Let’s go blue today. I feel like Bob Ross, every time I start with this. So the first thing I want you to do is I want you to avoid the one documentation. What I mean by double documentation is if it’s charted somewhere, you don’t need to chart it in your narrative. So this is epic. Epic is the, the most familiar, um, uh, electronic healthcare record, electronic medical record. Um, they are a multibillion dollar company. In order for facilities to get this type, they have to invest millions of dollars essentially. Um, they have their own engineers that go and work on this stuff. You. It’s very customizable. It’s extremely inter-operable, meaning that, um, it actually works with different types of other electronic health records. So like works with Cerner. So if you go to facility has Cerner, um, you can actually easily pull out a medical records.
Um, not too long ago I had to take my own Kiddo to the, to the emergency room. And, uh, we never actually, they hadn’t been in the hospital until they were, uh, I mean they were in the NICU essentially. And we had gone to our, we always take them to the, to the pediatrician and then we would go into the hospital and they’re like, oh, is this her date of birth is where, um, this where you guys looked like everything was able to be pulled up. And at first it really tripped me out and I’m like, wait a second, this is, this is totally, uh, what epic does, um, cause they were using epic, epic. So a great, great, great software if you have the opportunity to work with it. But what’s cool about epic is if you look over here, I’m actually gonna switch, uh, colors. Cause I want you to be able to see this. Yeah. And so Mary says that her facility uses it. It’s really awesome. So what’s really cool about this, this is an ICU. This is actually an ICU flowchart. What I mean when I say double documentation is that if you ever get this opportunity, like here, if I enter like let’s say here, um,
so you have these things called tabs, right? So these tabs here, but assigned pain, respiratory output, vascular access, um, is your flow sheets. There’s an assessment one. You can always like, you can rearrange these, like my assessment when I was always first. But here if we do, um, intake, I can say I can put five mils or so this would say like an SRE. Like there’s usually a dropdown, certain reason. Cool. Alright. So it’ll say like, Eh, s and you’ll save five mils and then it keeps track of everything. Um, if you have to co-sign for whatever reason, if that’s your of silly policy. But let’s say I give my patient a 1300, I give them out five mils of, um, let’s say, let’s say we go here and we give ’em five mils of a Hepburn flush. I’ve already documented here in the flow sheet, it’s gonna keep it in my, I know tab. There’s some times like an, I know Tablo here, but if this is here, do I need to go document it in my nursing narrative?
No, but he says, no, exactly. There’s no reason to do that. Doh Documentation does a couple of things. Number one, it increases risks for, uh, for false documentation. If I put five Hiller five here and then I go on my narrative and put seven, and there’s actually, now there’s a discrepancy. Now I’ve actually contradicted myself. So I’ve increased that risk. So if like let’s say me mall comes in and I give her five mils of saline, that’s all I can give her and all this. And she, um, she has a PE for whatever reason. Let’s use peas. In example, pulmonary embolism, well now there’s a discrepancy. When they go back, they’re like, well, did you give her fiber? Did you give her something? Or is this five mills that you’re supposed to give each? Are they on a fluid restriction? And now you’ve, instead of being like the total, it’s like 1200 that they’re supposed to be on and now you’re at like 1300 because every time you flush and you’ve done it a couple of times short, you’re shifting.
Now you’re a hundred mils, now you’re not following the orders. Now you’re us. Now you’re doing a lot of things. You’re actually increasing that risk. The second thing that it actually does is it actually wastes time. That’s a huge time waster because if I’m documenting at one place, why am I going to waste my time to go document somewhere else? It doesn’t make any sense. So if you have a flow sheet, it’s like this. They’re great, great, great things to use. Um, and if you put them in one place, don’t go put it in another. That’s what I mean by avoiding double documentation. Those go to the next slide. So paint a picture. If I, this is specifically about the nursing note or the nursing narrative and what we want to do with this is we want to say, hey, is there something that I cannot put in a flow sheet that I need to somewhere else that I need to document sometimes, uh, like if I go back.
So sometimes you’ll see things like it’s called, uh, it could be another one. It’ll say like critical value. So in this critical value, and I’ll say things like, it’ll look similar and it’ll say like, time notify, uh, what the, um, the value was, uh, who you notified, et Cetera. And that’s a place that you can document communication. But in this, the thing I want to say, uh, okay, so critical value, right? I’ve gotta let’s say the triptans are high, so you can actually put in your nursing unit, you put like critical value received, uh, see a flow sheet. What that does is it says, Hey, I actually, I’m making myself aware or making everybody else aware that this thing happened, but I don’t need to document everything about it. Another time that you’ll, that you can do this. Just like with the code, uh, there’s a thing called a code, a sheet or a code report sheet. Um, and what happens is during the code there’s someone who’s recording everything. And so like let’s say that there’s a code, so you, so, oh wait hundred, a, uh, like a c Coachee, right?
Sort of a code going on at like seven 45. You’re at the rest of your note, blah, blah, blah, blah. But then at eight o’clock you said, hey, see coachee. Because then they can actually go and reference that and you, you are then not responsible. What you want to do is you want to paint a picture and we’ll actually go through some of this a little bit. We’ll, I’ll type some things out to give you guys some, a little bit more direction. What I mean by painting a picture, but what you really want to do with it, if you want to say, Hey, what can I not document somewhere else? That’s what needs to know to go in the nursing narrative. So if you didn’t chart it, I want you to finish this in, in the chain. If you didn’t chart it, what
it didn’t happen. Yup. If you didn’t turn it didn’t happen. So what we, what we need to say is we need, you are responsible for the care that you give. You’re also responsible for the, uh, the your documentation. So if you gave, if you did addressing change, like let’s say you do a dressing change and for whatever reason you don’t have a sharp with you, you’re in the room, maybe their contact, you don’t have a Sharpie, you need to time to initial it, but you did it. But it’s not actually written on all of like, let’s say the policy is that, um, let’s see, let’s write a letter. So the policy says, um, all dressing changes, um, need to have a time, date, and initial. While you’re in that contact room, your patient has MRSE versa. Methicillin resistant, staph orients. So they’re are contact precautions. You don’t have a sharpie and you did your Jessie change. Well, what you need to do, the first thing you need to do is you need to document it what ever that is. So wait a hundred, um, dressing, um, removed,
wound assessment complete. And then you’ll say something like, uh, new, oh my goodness, I never actually write these out. Always type them new dressing applied, right? So this is your note for him. And then what you can do is go back and do it. But just because that, that dressing doesn’t have the time to initial on it, that you actually did it, you actually did the care and you’ve documented that you’ve done it. So even if something were to happen with that dressing, even if you didn’t follow the policy specifically in terms of time dating and initialing it, you did document that you did it. So it’s really important. Always make sure that you, you follow policy as close as possible. The other thing that you want to do here is like, let’s say you do a dressing change, right? So you do it and you go to give report.
Like, hey, I totally skipped and forgot to write. Uh, the attendant initial on that patient’s, uh, you know, chest tube dressing. Um, and did it, I did it eight o’clock. I just never got a chance to go. I totally, totally skipped my mind. Um, you can do a couple of things. The first thing you can go is go in there whenever you do your, your bedside and forth and do it. Then origins, ask the nurse to do it. I mean, that’s the other option. I’ve done that in real life. This is more, this tutoring session is more of a like a real life, um, type of thing because you’re not gonna get, you’re gonna get very few inklings questions on documentation, if any. Um, but this is more of a real life. I want you guys to be prepared what you’re actually gonna encounter. And that way you never put yourself up for risk of litigation.
You actually know, cover your ass on everything. So see why always. So let’s go to the next one. Never compromise care for turning. What I mean by this is that you usually never do anything. Now this actually will be on, on the, um, on the NCLEX and it usually is, uh, hey, um, you see this change in this patient. What is the one thing that you should do? And it’ll say something like, uh, document the findings. Well, it’s usually not the answer because there’s always something that should be done before that. Um, but what I mean by this is let’s say mimo comes in, she’s 93, she codes, um, I need to chart that I call the provider should chart that I’m calling the provider or should I take action for the patient?
yeah. And you want to take action on the patient. You want to actually do, like you could do all of these things. So we have things, this is called a, one of the things that we use in the hospital is called a time tape. What it is is it’s an eight by 11 and a half sheet of paper and we actually take it and fold it in half and fold it over. So now you have this half sheet of paper. And what we do is we have like our code stuff written out. So patients’ information, demographics, uh, code status. Then we have like systems, so neuro, cardiovascular and pulmonary Gig, you, um, musculoskeletal and teg and then carving always are broken down. And then on the other side of it, you’ll have like seven, eight, nine all the way down to like 1900. And what it does is like meds are given here, meds are given here, meds are given here.
But what you can do on this time tape is actually write things that happen. So, oh, eight o’clock, meanwhile coded. So I know that at eight o’clock when I go to write my nursing narrative, I can actually write this down, but it’s a place for me to do it. Oh, hey, I called the doctor at 12th grade. So this is a place that you can do it. And because you have this time tape or whatever a report sheet you have, this really helps in that. You’re writing it down, you can remember it and uh, you can come back and look at it later to actually put it in the medical records. My wife has always gotten on me. She was like, why do you have so much writing in your arms? I would actually literally write a things I needed to remember the times I did these things so that I would never forget them.
And so like you have to figure out ways to work around, uh, charting and remembering really important things. Like a blood pressure. Like if your patients like blood pressure’s one 20 over 80 and you go and you turn them and all of a sudden it drops 70 over 40 you better know what time it happened. A call, everything’s eight o’clock today apparently. So it happened at eight o’clock. Well, when am I remember it? And it may be like eight oh three and because you want to try to get as close as possible, you right away to a three in right BP. Guess what? You’ve actually given yourself a, like some of these things will actually be implanted, implemented into the Monitor. So they automatically will go into the electronic medical record. But here what you’re doing is you’re writing the time that you actually wrote it down.
So let’s go last one. Last thing we want to talk about is setting a routine. We talk about setting a routine. It’s you want to make sure that when you come in and you start documenting, you document it always the same way. This is the way I would do it. So if we go back to epic, here we go. So when we went to epic, this is what we do and just how I would do it. And you can, you have to figure out what works for you. It depends on your patient load. It depends on your unit. It depends on a bunch of things. But like I was in the ICU and we would always do report at bedside and erase all that stuff, but always do report at the bedside. And then what we do is I would go into review. First thing I would do is there was always a tab over here for sign off. So hey I got report at this time. I put it actually in end, you’ve put a a new time and then the report received from,
from John and then like they would end up on their side, put report given to oops to chance. Right. And so it would have that time, but then I’m going to go in and I’d start, all right. I would go actually go back in here to whatever tabs I needed to. I would review the h and p. Um, that would be something I’ll look at. So I need to know why they’re there. I would look at code status. Code status is usually up on the top in epic. Um, any allergies. So B, code h and p, allergies sign off. Now when I’d go to chart, I always started this side and went this way. So usually my assessment was first or I’m sorry, vital signs are first, then assessment and in the assessment you have lines, drains and airways and your and your tubes and stuff.
And then you would have like, um, uh, let’s see. Then you would have light plan of care and then you would have like, um, maybe a wound note. And then you would have likes your, you know, sign offs over here. So basically every time I started I would start over here and go this way. And so every time I would go to update my report, I’d go this way. And then like a nursing nurses note issued. Oh, so see like nurses right here, sort of here, it’s there. So then at the end when I go here, I’d go, Oh, I’m going to note and I’m going to write my nursing note. And then some time like in, uh, and then the skin notes of skin of the note writer is what they call it in epic. It’s actually over here. So that do my skin.
Okay, cool. If I need to do a dressing change, I’d put it there. So I would always do things in a certain routine. That way I’d never got out and that the end of the day I could go back and outward review it. Finally one time, Hey, my pain assessments, I’ve got to make sure that those are done every two hours. So make sure that, oh, those are done. Make sure my assessments are documented every four hours. Um, uh, I those are done. Uh, those were done. QA made sure all of those things are done in a timely manner. Um, so those, in doing your documentation, always make sure that you’re doing it in a certain way. So let’s talk about the nursing narrative and kind of how you want to write it. So let’s go. I’m actually gonna stop sharing my screen just for a second so I can pull up a new screen now. Actually I think I can do, bear with me. Let me see if this works. Your new tech thing. Cool. It works. Yeah. I don’t actually have to change my screen. Can I go? Let’s see if I can go full screen on this view. Full screen. Sweet. All right, cool. Everybody can see that, right?
oh my goodness.
Cool. Let me try one more thing. Try it. One thing here.
All right, let’s try it one more thing real quick. Actually, let me try one thing. Sorry guys. We’re doing something a little bit different than I haven’t done before. Let’s do this.
hang tight. One second guys.
Almost done. All right, look back. All right, cool. Let’s transfer our time.
Sorry guys. Sorry for the little delay. I just want to make sure that this looks right. All right, everybody should see a word document or I see that [inaudible]. Cool. All right, so let’s talk about documentation for a second. So let’s say you, um, oh, let’s talk about this for a second. Cause this is one of the things that drives me absolutely bonkers. So remember we talked about the flow sheets, right? So seven o’clock, this is actually, I would write my now seven o’clock. We are these things called timestamps or smart types. And what we do is you could do something like we actually have labeled as GDS end date, um, and description. And what would happen is you hit enter and it actually pulls up like t s 700, you know, actually put everything, which is really cool about epic. But what this is, you’ll say like court received a c flushing. I don’t need to say anything else about seven o’clock because I did it. Another thing you could say here is um, patient turn for skin assessment.
Basically what you’ve said here is that not a flow sheet where I have more information. The other thing about this is I also have, uh, I’ve also said that I’ve actually given report or receive report and I printed the patient and checked out the skin, which means that, and this is where our problem comes into, can sometimes have some skin breakdown. And so you want to make sure you get in for, you know, four people on it. So for eyes on, for people, oh eight o’clock rolls around, right? So eight o’clock you’re doing your assessment. So your assessment shows that you’re like, hey, assessment, complete safety check. We did safety checks complete. Oh I can’t spell today. Um, meds given her, Huh. Cool. See flow sheet or details. This is what I would see. This drove me insane anytime I would see anybody else’s. No, you can’t see what I’m typing too small. Let’s do this.
Oh, that’s weird. Hold on one sec.
That’s really strange. I don’t see it either. Hold on one second. Did they do,
let’s try this. Hold on now. Can you see it?
okay, cool. So talking about eight o’clock, right? So let me, let’s go back to seven cause you guys probably missed that. So seven o’clock I’m saying hey, report received. I looked at the patient, I ended up patient, I picked Jeremiah patient, we did a foreskin assessment with the ongoing nurse and I’ll say [inaudible] I didn’t need to put anything else in there at seven o’clock. Now eight o’clock rolls around, I’m going to do my assessment or remember back in that, um,
you guys can see it now, right? So Marissa still can’t see. Okay, cool. Yeah, you guys should be able to see it now because I can see it on my side. So for that assessment, I don’t remember. I’ve got that flow sheet. I don’t need to document that anywhere else. I just need to make sure that I put the assessment complete. I put my safety check complete. I gave them meds. Promar because in the medication administration record, I’ve got that thing there. The other thing is I’ve got the flow sheet. See the flow sheet for details. This is what I would end up seeing. This drove me nuts. I actually got to zoom out just a little bit so I can actually see, but you guys should still be able to get to see all that. Okay. I just want to see what reps, this is what I would see. Um, so instead of assessment complete, you get this patient [inaudible] and for patient anal types for neuro. And then they would start to describe, uh,
pupils for Brown risk reacting equal, uh, indirect PLRs, uh, positive. Um, you know, hair is easier to noted. Um, and then they moved to like Criteo and I’ll say, um, s one s to asco. Like they start to write all of this stuff up. And what I’m doing is I’m wasting a bunch of time by putting this somewhere else. There’s no reason that you should start typing up anything weird. What I will say is this, um, in your assessment if you like, um, there’s something that I can’t say, so he should alert and oriented times four. When we’re talking about orientation, we want them oriented to, um, I’m situation, um, and date of birth, right? I want to know a person, sorry, person plays with time, uh, and situation. So I want them to know that who they are, where they’re at, when it is and what’s going on. Like that’s for your, your uh, orientation times for if there’s something that’s abnormal that you can describe. So let’s say Peyton, so let’s say they’re not oriented to situation. What you can do is say in your, um, in your pledge sheet, you say patient oriented times three, not to situation and or not to time. And then here assessment you could say patient states, um, President Eisenhower
is next to me. Okay, cool. Mr President Eisenhower’s not the president anymore. Um, it was long time ago and that’s not the current situation, but you can’t accurately describe it in the flow sheet. So that’s where you can use these things. You also always want to say if a patient like, remember, remember your subjective and objective data. You want your see your patient’s subjective data in quotes all the time. Um, here’s, here’s one where it’s actually really important. So patient states this is the worst headache of my life. This is typical of something called sub arachnoid. Um, let me tell him that he mud. There you go. Um, it’s a, it’s an arterial bleed. It’s really important. This is a typical, typical presentation. Patient states this is a worst headache of my life. And the reason you want to put this, this because you’re documenting something prevalent that you can’t put it anywhere else. That’s really important to the patient’s current diagnosis. All of a sudden your patient has a neuro change. Now you’ve now, um, oh eight 15 m B Smith notified.
new order c stat CT, um, patient, um, packed for travel
off unit at Oh eight [inaudible]. Cool, great. What I’ve done, right? So just the type of stroke. So now what I’ve done is I’ve said in here, I call the provider, I received a new order, which is a stat CT. I’ve packed my patient for travel and then I’m off the unit in two minutes. I’ve documented everything I need to like I’ve called, I’ve done everything I needed to to get that patient out. So these are the types of things that you need to do in your narrative and saying, Hey, I’m putting all of this together. I’m, I’m writing this thing in a way that does that I can’t put anywhere else. And that’s what the point of documentation did. The nursing narrative. It is. So I want to take a couple of questions and maybe try to, if you guys want some tips and tricks, um, as far as documenting something that I can write down for you and how I would write it.
Um, I know at one time we talked about a fall, um, you never want to admit fault in a nursing narrative. You want to write objective, you want to write your objective statements for it. So, uh, if you see a fall, you wouldn’t see patient fell. It’s patient observed on floor, patient assessed, where can I get a list of abbreviation? Here is what I would say. I would say, let me see if I can pull up a link for you guys. In the background. Um, here’s what I would say is I’m going to give you a list of, I’m going to give you a list of, uh, something called who not use list. And what this is, is these are abbreviations that you should not ever use, um, because they actually put you more at risk for off documentation. Sorry guys, I want to in here. Um, let me go back to this. What I want to do. Like I said,
um, this is the list of things you should not ever use in terms
refresh your page. Yeah, it’s a lot. It can be a long list. So the ones you want to avoid or are like, they’re more like concepts. So if you get this concept of, Hey, um, let me actually look at the list real quick. Actually, the list is not that long as it’s not as long as it used to be. So you want to avoid things like unit. You want to avoid things like leading and trailing zeroes. You want to know, uh, you know which one the list is actually not as long as it used to. Yeah. It’s only one page. The current most current list which was done in Oh nine, which is the most current list actually has a lot of things. Yeah. I used to do this all the time. Like I used to write a micrograms, but I’d use like the little you, but so DC is one discontinue, however, DC can also stand for discharge. So you want to be very careful in how you’re using it. Um, so, um, for instance, in veterinary medicine where I worked before, we would actually use this thing where it’s like a p with a line over it, which actually stood for patient in veterinary medicine. But, uh, when that translated into,
Marissa, if you need to go, you are more than welcome to, you know, nobody is required to stay. Uh, if you do have questions, I’m here to answer them for you. But, uh, you know, I don’t want anyone that’s ever feel like they’re obligated to say these tutoring sessions. Um, but in terms of some of the abbreviations, you just need to make sure that the abbreviations are relevant and they’re contextually accurate. So those kinds of things. So if you guys have any questions I can, you know, I’d be more than happy to answer for the answer them for you or Kinda type out what I went to. Uh, cause those were, you know, some people just need a little bit of guidance in terms of, uh, what they want to, um, what’s important for them to document. All right guys. Well, we don’t have any questions. Uh, you know, we’re going to be back. I know that Nicole is about to come on and about 25 minutes to do, uh, a farm lesson on, uh, on antihypertensives. And so that’s going to be really beneficial for you guys. So I encourage you to go check that out. Um, and as we always say, have a great day and happy nursing.