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17 Tips to Improve Your Nursing Documentation

Documentation in nursing is a key factor in our role and responsibility as a patient care
advocates. It is critical for determining if the standard of care was rendered to a patient to defend
prior nursing actions. Failure to chart, omissions, and poor communication are hard to defend.

Whether you are a seasoned nurse or a new grad, here are 17 tips worth reviewing:

A better option is “MD paged, assessment findings discussed, and no additional orders at this
time.”

1. Be extra careful when you think you are "too busy." It is ironic that it is at your
busiest hour(s) that the importance of documenting is the most crucial. Be aware of
critical times such as:
o abnormal vital signs
o codes
o transfers
o change of nursing shift or patient hand offs
o taking verbal orders
o noting physician’s orders
o verifying medication orders
2. Remember that critical values should be reported to a nurse within 15 minutes of lab
verification.
3. The nurse must report critical values to the physician within 30 minutes. If the
physician can’t be reached, follow the facility’s fail safe plan.
4. Avoid general statements. Beware of general statements that can be misconstrued. For
example, you wrote “Dr. Smith called.” Did you mean:
o you called and are waiting for a return phone call?
o the physician called the nurse?
o the nurse called and spoke to physician?
A better option is “MD paged, assessment findings discussed, and no additional orders at
this time.”

5. Some facilities use nursing charts by exception. They indicate findings are “within
defined limits” (WDL) unless otherwise noted. Know these defined limits. Charting by
exception requires selecting “abnormal” and writing applicable text. In such cases, text
will be carefully scrutinized.
6. Regardless of the charting method used, nursing documentation must be:
o Objective
o Legible
o Free of grammatical/spelling errors
o Free of errors/erasures
o Completed in blue or black ink
o Accurate

7. Late entries and any corrections entered should be per policy and procedure.
8. Allergies should be highlighted and flow sheets filled out completely.
9. No charting should be done in advance.
10. Charting patterns including flow sheets will be reviewed. “Too perfect” charting may
raise doubts. Patient assessment such as fall risk or skin assessments must be carefully
performed and documented. Failing to do so is a common error.
11. Documentation should include staff notified and steps taken. Careful nursing
assessment makes spotting changes in the patient’s condition easier. One
recommendation is the DARE approach: document Data, Action, Response, and
Evaluation. The RN is responsible for analyzing data.
12. Consult the nursing policy and procedure for accepted abbreviations. Sign each
entry correctly, including date and time. An illegible signature may lead to all nurses on
duty being named in order to “cast a wide net.” Date and time are crucial when creating
a chronology of events.
13. Take caution with frequent flyers. It is easy to spot staff’s judgment. The nurse
applied oxygen on one patient complaining of an impending sense of doom and
documented, “Patient recovered from her previous little episode.” It was the last entry
before the patient died.
14. Evaluate any new onset of pain. One patient suddenly complained of a new onset of
debilitating headache after he fell and hit his head in the hospital. This is documented as a
“migraine” although there is no previous history of migraines. 12 hours later, a CT scan
revealed brain stem herniation.
15. Hospital bills will be audited for items such as tubing charges, etc. to determine if
policy and procedure was followed to prevent infections.
16. Always use a disclaimer. Privacy issues include retaining back-up records for prescribed
time and avoiding fax and e-mail when possible.
17. The statute of limitation is typically 2 years. Medical malpractice cases may be filed
up to the end of these 2 years. It may take several more years before a potential case goes
to trial. Hence, a nurse may still be testifying long after the events.
To avoid all these troubles, it is important that you pay attention to nursing documentation. It
may not just save your patients' lives—it might save your career, too.

Nursing Reports is an open access, peer-reviewed, online-only journal that aims to influence the
art and science of nursing by making rigorously conducted research accessible and understood to
the full spectrum of practicing nurses, academics, educators and interested members of the
public. The journal represents an exhilarating opportunity to make a unique and significant
contribution to nursing and the wider community by addressing topics, theories and issues that
concern the whole field of Nursing Science, including research, practice, policy and education.
The primary intent of the journal is to present scientifically sound and influential empirical and
theoretical studies, critical reviews and open debates to the global community of nurses. Short
reports, opinions and insight into the plight of nurses the world-over will provide a voice for
those of all cultures, governments and perspectives.

The emphasis of Nursing Reports will be on ensuring that the highest quality of evidence and
contribution is made available to the greatest number of nurses.

Nursing Reports aims to make original, evidence-based, peer-reviewed research available to the
global community of nurses and to interested members of the public. In addition, reviews of the
literature, open debates on professional issues and short reports from around the world are
invited to contribute to our vibrant and dynamic journal. All published work will adhere to the
most stringent ethical standards and journalistic principles of fairness, worth and credibility.

Our journal publishes Editorials, Original Articles, Review articles, Critical Debates, Short
Reports from Around the Globe and Letters to the Editor.

In the busy working day of a nurse, with the many urgent demands on your time, you may feel
that keeping nursing records is a distraction from the real work of nursing: looking after your
patients.

This cannot be more wrong! Keeping good records is part of the nursing care we give to our
patients. It is nearly impossible to remember everything you did and everything that happened on
a shift. Without clear and accurate nursing records for each patient, our handover to the next
team of nurses will be incomplete. Needless to say, this can affect the wellbeing of patients.

In fact, the quality of our record keeping can be a good (or bad) reflection of the standard of care
we give to our patients: careful, neat, and accurate patient records are the hallmarks of a caring
and responsible nurse, but poorly written records can lead to doubts about the quality of a nurse's
work.

Another important consideration is the legal significance of nursing records. If a patient brings a
complaint, your nursing records are the only proof that you have fulfilled your duty of care to the
patient. According to the law in many countries, if care or treatment due to a patient is not
recorded, it can be assumed that it has not happened. Poor record keeping can therefore mean
you are found negligent, even if you are sure you provided the correct care - and this may cause
you to lose your right to practise.
In short, the patient's nursing record provides a correct account of the treatment and care given
and allows for good communication between you and your colleagues in the eye care team.
Keeping good nursing records also allows us to identify problems that have arisen and the action
taken to rectify them.

‘Keeping good nursing records allows us to identify problems that have arisen and the
action taken to rectify them’

In this article, we discuss how to be effective in your record keeping and how to maintain the
high standards required.

Who is responsible for record keeping?


Anyone on the nursing team who provides patient care can contribute to record keeping.
However, if you are a qualified or senior nurse supervising unqualified colleagues, you should
assume responsibility for providing guidance on documentation.

What should go into a patient's nursing record?


The nursing record is where we write down what nursing care the patient receives and the
patient's response to this, as well as any other events or factors which may affect the patient's
wellbeing. These ‘events or factors’ can range from a visit by the patient's relatives to going to
theatre for a scheduled operation.

If you are in any doubt about what to write down, it may be useful to ask yourself the following:
“If I was unable to give a verbal handover to the next nursing team, or the next shift, what would
they need to know in order to continue to care for my patients?” You want to ensure that the
patient's care is not affected by the changeover of nursing staff.

How to keep good nursing records


The patient's record must provide an accurate, current, objective, comprehensive, but concise,
account of his/her stay in hospital. Traditionally, nursing records are hand-written. Do not
assume that electronic record keeping is necessary.

 Use a standardised form. This will help to ensure consistency and improve the quality of
the written record. There should be a systematic approach to providing nursing care (the
nursing process) and this should be documented consistently. The nursing record should
include assessment, planning, implementation, and evaluation of care.
 Ensure the record begins with an identification sheet. This contains the patient's personal
data: name, age, address, next of kin, carer, and so on. All continuation sheets must show
the full name of the patient.
 Ensure a supply of continuation sheets is available.
 Date and sign each entry, giving your full name. Give the time, using the 24-hour clock
system. For example, write 14:00 instead of 2 pm.
 Write in dark ink (preferably black ink), never in pencil, and keep records out of direct
sunlight. This will help to ensure they do not fade and cannot be erased.
 On admission, record the patient's visual acuity, blood pressure, pulse, temperature, and
respiration, as well as the results of any tests.
 State the diagnosis clearly, as well as any other problem the patient is currently
experiencing.
 Record all medication given to the patient and sign the prescription sheet.
 Record all relevant observations in the patient's nursing record, as well as on any charts,
e.g., blood pressure charts or intraocular pressure phasing charts. File the charts in the
medical notes when the patient is discharged.
 Ensure that the consent form for surgery, signed clearly by the patient, is included in the
patient's records.
 Include a nursing checklist to ensure the patient is prepared for any scheduled surgery.
 Note all plans made for the patient's discharge, e.g., whether the patient or carer is
competent at instilling the prescribed eye drops and whether they understand details of
follow-up appointments.

Patients' records must provide an accurate account of their hospital stay. SOUTH AFRICA

Elmien Wolvaardt Ellison

Writing tips
 Ensure the statements are factual and recorded in consecutive order, as they happen. Only
record what you, as the nurse, see, hear, or do.
 Do not use jargon, meaningless phrases, or personal opinions (e.g., “the patient's vision
appears blurred” or “the patient's vision appears to be improving”). If you want to make a
comment about changes in the patient's vision, check the visual acuity and record it.
 Do not use an abbreviation unless you are sure that it is commonly understood and in
general use. For example, BP and VA are in general use and would be safe to use on
records when commenting on blood pressure and visual acuity, respectively.
 Do not speculate, make offensive statements, or use humour about the patient. Patients
have the right to see their records!
 If you make an error, cross it out with one clear line through it, and sign. Do not use
sticky labels or correction fluid.
 Write legibly and in clear, short sentences.
 Remember, some information you have been given by the patient may be confidential.
Think carefully and decide whether it is necessary to record it in writing where anyone
may be able to read it; all members of the eye care team, and also the patient and
relatives, have a right to access nursing records.
Looking after nursing records
Keep the nursing records in a place where they can be accessed easily; preferably near to where
the nursing team meet at shift change times. This will ensure that records are available for
handover sessions and also that they are easily accessible to the rest of the eye care team. The
handover may take place with the patient present, if appropriate. Indeed, nursing records can
only be accurate if patients have been involved in decision making related to their care.

File the nursing records in the medical notes folder on discharge. Ensure that the whole team
knows if nursing records are stored elsewhere.

How can nursing records contribute to VISION 2020?


Accurate records will contain observations of clinical outcomes, for example, how an elderly
patient has benefited from his or her cataract operation or how skilled the patient is at instilling
eye drops before discharge. Such information can be used in clinical audit and reports on clinical
activity. This contributes to research and performance data which can be used to monitor
improvement in service delivery and outcomes, all of which ultimately contributes to VISION
2020. It is not only medical notes that are important; well-written nursing records will provide
qualitative comment on treatment outcomes.

INFORMATION ABOUT WRITING EXPECTATIONS IN NURSING

Nursing Education

The profession of nursing includes several subdisciplines and various career pathways. Among
these include education, administration, research, or practice. One of the factors determining the
career pathway one pursues is education. Nursing is unique, for it provides more levels of initial
preparation than other professions due to the variety of educational pathways that one can take to
become a Registered Nurse (RN). “In 2004, of the 2,909,467 licensed RNs, 17.1% had diplomas
as their highest nursing related educational preparation; 33.7% held associate degrees; 34.2% had
baccalaureate degrees; and 13% held master’s or doctoral degrees" (U.S. Department of Health
and Human Services, 2006). What does this tell us? There is a significant educational disparity,
which is most evident in the rift between nurses with associate degrees and master’s or doctoral
degrees.

Therefore, whether nursing majors obtain their education at a community college or state
university and though the curriculum may differ, they equally have the same opportunity to
become a Registered Nurse, granted that they successfully pass the licensure exam, the NCLEX-
RN (National Council Licensure Exam). The difference in attending a state university such as
California State University, Sacramento versus other institutions is the opportunity of a
baccalaureate education and graduating with a Bachelor’s of Science in Nursing (BNS).
Furthermore, graduate school prepares the graduate nurse to earn a Master’s of Science in
Nursing (MSN) and become a Family Nurse Practitioner, Advanced Practice Nurse, or Clinical
Nurse Specialist and go into various specialty areas such as cardiology, oncology, neurology,
pediatrics, etc.

Since the majority of nursing graduates’ professional experience begins as Registered Nurses,
educational information regarding writing expectations and standards in a career as a Registered
Nurse will be provided on this website. Secondly, information regarding writing expectations
and standards at the graduate and post graduate level will be presented. Additionally, a look at
one of the significant and iconic figures in the history of nursing and her contributions to the
profession of nursing will be discussed. Lastly, various resources for writing in nursing as a
student and as a professional are compiled at the end of this presentation.

Historical Context of Nursing

There are numerous nursing leaders in history who have provided the profession of nursing with
the essential framework for nursing practice and development, but none more well-renowned
than Florence Nightingale. As such, we can credit nursing’s heroine and founder of modern
nursing to the notable Florence Nightingale. Nightingale was born into a traditional aristocratic
family in Victorian England. She felt greatly divided and constrained between conforming to her
family and social obligations versus her passion to pursue her dreams in helping the poor and
caring for the sick. On February 7, 1837, Nightingale heard, by her account, the voice of "God"
telling her that she had a mission in life, and after a few years of soul searching, she discovered
that it was nursing. Through her determination and commitment, Nightingale made a tremendous
impact in the Crimean War as she led a small group of untrained women to the British hospital in
Scutari and applied her passion and expertise to care for the wounded soldiers. Remarkably,
Nightingale’s educational skills and resourcefulness enabled her to gather very detailed statistics
on morbidity and mortality in respect to the sanitary conditions of hospitals in Scutari. As a
result, her contributions led to the historical reform of the military’s healthcare system.

Furthermore, perhaps one of Nightingale’s greatest contributions is her most noteworthy


publication, Notes on Nursing: What It Is and What It Is Not. In this she writes, “I use the word
nursing for want of a better. It has been limited to signify little more than the administration of
medicines and the application on poultices. It ought to signify the proper use of fresh air, light,
warmth, cleanliness, quiet….all at the least expense of vital power to the patient”. Throughout
the document, Nightingale continues to write the philosophies of the basic necessities of nursing
care and the needed hospital reforms to improve conditions and the importance of “mastering a
unique body of knowledge” for any individual who wish to study and practice professional
nursing. Nightingale’s “Notes on Nursing” created the fundamental foundation for the writing
expectations in nursing in the years to follow.

The Registered Nurse

 Writing Expectations for Associate Degree and Baccalaureate Degree in Nursing


What is a Registered Nurse?

“A Registered Nurse is a nurse who has completed at least an associate’s degree in nursing
(ADN) or a bachelor of science degree in nursing (BSN), and has successfully passed the
NCLEX-RN certification exam”. – Healthcareers.com

There are two common routes in which an individual can pursue a degree in nursing. The two
most common is an associate degree and a baccalaureate degree. An associate degree can be
obtained by attending a community college. A baccalaureate degree can be obtained by attending
a state university, such as Sacramento State University. The type of path one commits to depends
on the individual. Existing factors that play a part in this decision potentially include personal
and future academic plans, finances, or impaction of nursing programs. For instance, individuals
planning on advancing to graduate school must have a baccalaureate degree as a pre-requisite.

Dr. Altmann, comments on the writing expectations and distinctions between the two:

“The expectations at the associate degree level is to be clear, concise, and articulate in a short
amount of space. Most of the type of writing at this level is patient documentation and the
requisite is that if the chart were to go to court, the information would not be challenged due to
inaccuracies or confusion. At the baccalaureate level, it is expected that the RN could also write
short articles for publication and become involved in nursing research. This would require a
higher level of writing sophistication”. –Dr. Altmann, professor of Nursing at CSUS.

As a registered nurse, there are many different career pathways, which include hospital-based
nursing, community health nursing, nurse entrepreneurs, office-based nursing, occupational and
environmental health nursing, and many more. As of 2004, hospitals are the primary work site in
which RNs provide direct patient care, or serve as educators, supervisors, and managers. Most
hospital institutions are organized into specific “units” or departments, which can include
medical-surgical, pediatrics, coronary care, emergency department, and various intensive care
units. The writing expectations of an RN providing direct patient care mainly deals with charting
and documentation into a patient’s medical record. RN’s who hold management, coordinators, or
other higher level positions may assume the responsibility in writing or evaluating hospital
policies and procedures, creating quality improvement projects, or providing hospital education.

Charting/Documentation

 Purpose of Charting/Documentation

Much of the writing involved in being a registered nurse is through charting. Charting is a tool
that has evolved over time and continues to evolve as evidenced by the conversion from a paper
to paperless system. The terms “charting” and “documentation” can sometimes be used
interchangeably especially in the hospital setting. Documentation is defined as anything written
or printed and is an integral aspect of nursing practice. Proper documentation serves many vital
purposes which include:

 Ensuring continuity of care


 Maintaining quality of care by adhering to standards of regulatory agencies and standards
of nursing practice
 Minimizing the risk of errors and enhancing safety
 Financial Reimbursement
 Legal guidelines
 Education
 Research
 Audit-Monitoring

 Content

The content of the information documented in a patient’s medical record provides a formal and
detailed account of the quality of care provided to a patient. Standard patient record or chart
contains the following:

 Patient identification and demographics


 Informed consent for treatment and procedures
 Admission nursing history, nursing diagnoses or problems, and nursing multidisciplinary
care plans
 Record of nursing care treatment and evaluation
 Medical history and medical diagnosis
 Therapeutic orders
 Medical and health discipline’s progress notes
 Reports of physical exams, diagnostic studies
 Client education
 Operative Procedures
 Discharge Plan and summary

(Potter, PA & Perry, AG, 2009)

 Style

What constitutes effective and proper documentation? Nursing documentation should include the
following characteristics:

 Factual – objective information using the nurse’s direct observation of patient. Avoid
using opinionated or vague statements, Record subjective data (patient’s own words) in
quotation marks.
 Accurate – to ensure accuracy, all entries are dated, timed, and clearly identifies the
author and their title. Accepted medical abbreviations are used, correct spelling,
punctuation, and grammar is carefully considered.
 Concise – entries need to be clearly and easily understood
 Complete – ensures thorough documentation and communication
 Current – emphasizes the critical component of documenting in a timely manner. For
example, once you complete performing patient care, you immediately document the
time to which you performed the care. The military time is the standardized time used for
many health care agencies because it avoids the misinterpretation of AM and PM times.
 Organized – having all the required information available before documenting in the
permanent legal medical record.
 Formal – using professional language to document patient care
 Objective/subjective

Inappropriate Example: “Patient was acting out”


Appropriate Example: “Patient appears restless, getting up from chair and pacing back and forth
repeatedly, fist clenched, and frequently yelling at staff, ‘I hate this hospital!’ ”

Patient documentation is mainly formal, factual, and objective. Most standard forms include a
template in which you fill in the required information using various assessment scale tools. Some
sections provide a narrative note where nurses can combine subjective (usually from the patient’s
own words) and objective data. Nurses utilize abbreviations with many shortcuts and acronyms
utilizing appropriate and approved medical abbreviations when charting such as SOB (short of
breath), LOC (level of consciousness), OOB (out of bed), etc. For a detailed list of approved
medical abbreviations please visit Jeremy’s Abbreviation link.

Example of using medical abbreviations in a narrative note:


1-1-11/0700: Pt post op #2, AAOx3, VS assessed and stable. Bilateral crackles on LLL and RLL.
CXR positive for infiltrates on LLL. Pt instructed to use IS q hr and OOB tid. Consult with RT at
0800 and PT at 1000. ---------------------------------------------------- Signature, Title.

 Audience

1. Health care professionals – communication among nurses, physicians, respiratory therapist,


occupational therapist, and other members of the multidisciplinary health care team.
2. Legal – for legal claims and issues such as lawsuits
3. Agencies – Joint Commission on Accreditation of Healthcare Organization (JCAHO),
Occupational Safety and Health Administration (OSHA), Center for Disease Control (CDC)
4. Patients
5. Researchers
6. Educators

 Types of Charting

Charting differs from hospital to hospital. Some institutions have adopted computerized charting
such as the Electronic Medical Records (EMRs) where other institutions are still using paper
charting. Some of the most common types of documentation system include:
1. Narrative – most registered nurses are expected to write in a formal narrative style, using a
story like format with events in chronological order. Objective and subjective data can both be
included.
Example of a narrative note:
1-1-11(date)/1300(time using military standard): Patient awake, alert, and oriented. Patient ate
50% of breakfast. Patient reports feeling 6/10 sharp shooting non radiating pain on right lower
knee. Patient given Hydrocodone 5mg/500mg orally. After thirty minutes, patient reports feeling
3/10 and declines sharp or shooting pain. VS assessed and stable. Assumed patient care.-----------
------------------------------------Signature, Title.

2. Problem-Oriented – centers on patient’s problems or diagnoses. The content has four major
sections:

 Database
 Problem List – includes a holistic assessment (i.e. physiological, social)
 Care Plan – includes nursing diagnoses, interventions, outcomes, and evaluation based on
the patient’s response from the interventions
 Progress Notes – evaluates the interventions provided and assesses current care plan.
Progress notes comes in various formats:
o SOAP = Subjective, Objective, Assessment, Plan, Interventions, & Evaluation
o PIE = Problem, Intervention, and Evaluation
o DAR = Data, Action, Response or evaluation
o PES = Problem, Etiology, Signs and symptoms

3. Source Records – patient’s chart is organized into separate sections for each discipline
(nursing, physician, respiratory therapist).

4. Case Management & Critical Pathways – integrates the key interventions and expected
outcomes from a patient’s problems using data gathered by the multidisciplinary health care
team into one central care plan.

Other Forms (link bullet point)


Registered Nurses have a variety of forms to fill out in which they integrate into a patient’s
medical record. Among these include:

 Admission nursing history


 Flow sheets & Graphic Records – i.e. Input and Output sheets, vital signs
 Client care summary or “Kardex”
 Discharge summary forms

These forms are kept in a patient’s medical record to make up a comprehensive assessment to
provide the best quality of care for each patient.
 The Graduate/Post Graduate Nurse

The advanced practice nurse holds at the minimum a master of science in nursing (MSN). Some
of the writing expectations of a master’s or doctoral level nurse include: scholarly research,
professional publication, and writing literature reviews. Thus, their contribution to the scientific
community and their specific nursing discipline is significant. This section will explore science
and the scientific method used in nursing research, the steps of the research process, introduction
to nursing research, and the roles of nurses in research.

Dr. Altmann and Dr. Kelly share their thoughts on undergraduate and graduate writing
expectations in nursing:

Dr. Altmann, professor of nursing comments, “At the graduate level, the RN is expected to do
more professional publication. Since an RN at this level is expected to be engaged in research or
quality improvement projects, they are also expected to disseminate this information”.

Dr. Kelly, professor of nursing comments, “Once in the graduate level, the students is expected
to begin to provide valid critique of literature and to model scholarly approach to issues and
concepts. The graduate level student begins to learn the value of literature reviews and research
in nursing. The application of that research become part and parcel of the leadership role that
we expect of the graduate level RN”.

 Science and the Scientific Method in Nursing Research

Sound science requires that research be based on one or more past scientific works or studies and
is critiqued and acknowledged by the scientific community. Each academic discipline in the
scientific community has varied methods and tools in conducting research; however, one of the
commonalities in most if not all disciplines is the use of a systematic way of organizing and
solving problems. The scientific method is a universal systematic tool that can be applied when
doing scientific research. The steps of the scientific method include:

 Ask Question
 Background Research
 Construct Hypothesis
 Test the Experiment
 Analyze Results and Draw Conclusion
 Report Results

Of the two most common types of data collection methods, nursing utilizes qualitative research
to explore individual response through narrative interviews of nurses and patients, observation of
participants, and open ended survey responses. Quantitative research which predominately relies
on statistical analyses or numbers is often not as applicable to nursing research as is qualitative
research.

Furthermore, applied science is most commonly used in nursing research. Applied science uses
the discoveries of “pure science” in an attempt to apply it in some practical way (i.e. clinical
setting). “Applied science is usually referred to as clinical science now—taking to the patient’s
bedside those findings that may be useful in curing, managing, or preventing disease or
managing symptoms” (Black & Chitty, 2007, p.254). Additionally, nursing research uses both a
combination of inductive reasoning which moves from specific to broader generalizations and
deductive reasoning processes which moves from general to more specific, as both are equally
valued and significant.

As nursing research continues to evolve and refine in its methods, researchers have found that
the scientific method and quantitative research approach has limitations when applied to theories
and practices unique to nursing:

“The first and most obvious drawback is that health care settings are not comparable with
laboratories….Second, human beings are far more than collections of parts that can be dissected
and subjected to examination…it fails to consider the meaning of patients’ own experiences, that
is, their subjective view of reality” (Black & Chitty, 2007, p.256).

 The Research Process

The following are the steps of the research process used in nursing research:

1. Identification of a research problem


2. Review of literature
3. Formulation of the research question or hypothesis
4. Design of the study
5. Implementation
6. Drawing conclusions based on findings
7. Discussion of implications
8. Dissemination of findings

(Black & Chitty, 2007, pg.260)

 Nursing Research

The writing expectations of an advanced practice nurse or clinical nurse specialist are primarily
focused on nursing “research”. What is nursing research? The National Institute of Health’s
National Institute of Nursing Research (NINR) describes their mission and philosophy, “to
promote and improve the health of individuals, families, communities, and populations” (Black
& Chitty, 2007, pg.256). Therefore, nursing research has a significant emphasis in nursing
practice because much of the research arises out of clinical observations ultimately design to
improve the quality of patient care.

The science of nursing encompasses nursing practice, research, and nursing’s scientific base.
Nursing research developed to identify itself as a “profession” amongst all the other well-
established and accepted professions and to base its nursing care on evidence-based practice and
not simply on trial and error. As a result, nursing researchers and nursing theorists began
developing a scientific body of knowledge and theories unique to nursing. In the early
development of nursing research, nurses relied on trial and error methods to manage common
patient problems. Gradually, the emergence of evidenced-based practice circulated, which
focused on research- based knowledge in which nursing researchers can study and nurses in
practice can apply.

What is evidenced-based practice and its significance in bridging the gap between nursing
research and nursing practice? Sigma Theta Tau, which is the International Honor Society of
Nursing, has been a strong advocate for nursing research as evidenced by their position
statement: “The society defined EBN as an integration of the best evidence available, nursing
expertise, and the values and preferences of the individuals, families, and communities who are
served” (Sigma Theta Tau International, 2005).

Therefore, the use of evidenced-based practice helps bridge the gap between research and
practice because it requires nurses to base their care and activities on research-based knowledge.
For example, many research has been done on topics relevant in nursing practice such as
pressure ulcers, fall risks, ventilator associated pneumonias, proper hand washing, etc in order to
improve the standards and quality of care.

The relevance and application of nursing research plays a significant role in the advancement of
our profession and the standards of care of our patients. Nursing research is published in
scholarly journals and peer reviewed journals. To review the literature, you can search the
journals online, search your hospital’s database, or conduct a search through your school’s
library database. Here is a list of some of the nursing related journals:

 American Journal of Nursing


 Advanced Nursing Practice Journal
 The Nurse Practitioner: The American Journal of Primary Health Care
 International Journal of Nursing Practice
 Journal of Cardiovascular Nursing
 American Association of Nurse Anesthetists Journal

For a list of more nursing journals, please visit:


http://www.nursingschools.net/blog/2009/04/100-scholarly-open-access-journals-for-nurses/

 Roles of Nurses in Research


Table 11-2 Levels of Educational Preparation and Participation in Nursing Research

Level of Preparation Level of Research Participation


Student Nurse Consumer
BSN nurse Problem Identifier
Data Collector
MSN nurse Replicator
Concept tester
Doctoral nurse Theory generator
Postdoctoral nurse Funded program director

(Black & Chitty, 2007, pg.270).

This table shows the different levels of research participation of the different levels of nursing.
According to the table, the basic student-level nurse participates as a consumer and has the most
minimal role in research. The baccalaureate nurse has a more specific role and takes on
identifying problems and collecting data pertinent to the research. The role of a MSN nurse takes
on more responsibility in the research process. They replicate the experiment and test the
concepts. Finally, nurses with doctorate degrees assume the responsibility in generating new
theories or contributing to existing theories. The amount of education, clinical practice, and
research experience are all contributing factors in being successful in the research process.

 Interview with Nursing Professors

What do you think students in this major should learn about writing and why? How do you
incorporate writing in your course?

”For the beginning student, it is essential that they learn to express patient care objectively,
succinctly, and clearly. In my courses, they do this with documentation practice exercises.
Additionally, they need to learn to use the professional standard style of writing, which is APA.
To facilitate this, I have short writing assignments which require the students to include
references writing in APA style” – Dr. Altmann

“Students definitely need to learn to write in a 'scholarly fashion' for nursing. Nursing leaders
need to be able to convey ideas clearly and concisely while using technical language. For the
purposes of Nursing 123, it is important that my students can convey their interpretation of the
pathophysiology as it applies to their patient along with generating an understanding of the
clinical findings and tying them together to create a complete picture of the patient and their
needs”. – Dr. Kelly
How is writing in your profession different from academic writing?

“It differs depending on its purpose. If doing patient documentation, it is not academic writing ---
just the facts are needed. If done for publication or presentation, it is academic writing”. –Dr.
Altmann

“In many ways it is the same. The 'scholarly approach' is very important, the use of technical
language is appropriate and the critique of research is essential. A factual and concise approach
is highly valued. The discipline of nursing is one that overlaps with other disciplines; therefore,
we often borrow from the social sciences, medicine, as well as other hard sciences. We often use
models and theories developed in other disciplines to validate research that is done in the context
of nursing”. –Dr. Kelly

Did you feel nursing school prepared for the type of writing in your profession? If so, how
did you learn?

“My undergrad prepared me for patient charting. My graduate courses prepared me for
publishing. For graduate learning, much was done by trial and error”. – Dr. Altmann

“My undergraduate program only scratched the surface for me. I learned a great deal about
writing as a director when I had to submit proposals, policies, and procedures for review and
approval. In my master's program, I further developed my skills and my efforts at scholarly
writing improved dramatically. In my doctoral program it was expected that I write well.
Publication was a requirement and the process of editing evolved substantially”. – Dr. Kelly

Do you practice professional writing in your career? If so, what type of writing, purpose,
and who is the audience?

“As a nursing faculty, I am expected to publish regularly. For this I engage in both research and
creative scholarship. The audience depends on the nature of the article. I am also a staff nurse so
my writing there is patient care documentation. The audience is the healthcare team”. –Dr.
Altmann

“Yes, it is essential. I write for professional journals, contribute to standards of care, policy and
procedure. In addition, I write opinions relative to litigation in the field of nursing and
medicine”. –Dr. Kelly

Have you taken any writing refresher courses since you have graduated? Do you have on
the job training on charting or on any new skills related to writing?

“It is a constant process, always learning to improve my writing. Reading many journals and
texts is part of the learning process. Practicing my skills as I submit writings for publication. The
editorial process is arduous and requires close examination of the submission”. – Dr. Kelly
LINKS TO MORE RESOURCES FOR WRITING IN NURSING

 Resources for Writing in Nursing

 George Mason University: A Guide to Writing in the School of Nursing -

Presents information on the different types of writing found in the profession of nursing and
offers helpful advice from professors in the discipline.
http://chhs.gmu.edu/writing/index

 UCLA Graduate Writing Center -

A compilation of different writing resources in Nursing including nursing-specific textbooks,


links to online journals, and various websites. The writing resources are broken down in several
categories including writing for class, publication, and on the job.
http://gsrc.ucla.edu/gwc/resources/writing-in-nursing.html

 University of Virginia School of Nursing –

Provides information on APA including proper use of page setup, grammar, abbreviations,
punctuation, figures & tables, in text citations, and reference list.
http://www.nursing.virginia.edu/students/writing/

In the busy working day of a nurse, with the many urgent demands on your time, you may feel
that keeping nursing records is a distraction from the real work of nursing: looking after your
patients.

This cannot be more wrong! Keeping good records is part of the nursing care we give to our
patients. It is nearly impossible to remember everything you did and everything that happened on
a shift. Without clear and accurate nursing records for each patient, our handover to the next
team of nurses will be incomplete. Needless to say, this can affect the wellbeing of patients.

In fact, the quality of our record keeping can be a good (or bad) reflection of the standard of care
we give to our patients: careful, neat, and accurate patient records are the hallmarks of a caring
and responsible nurse, but poorly written records can lead to doubts about the quality of a nurse's
work.

Another important consideration is the legal significance of nursing records. If a patient brings a
complaint, your nursing records are the only proof that you have fulfilled your duty of care to the
patient. According to the law in many countries, if care or treatment due to a patient is not
recorded, it can be assumed that it has not happened. Poor record keeping can therefore mean
you are found negligent, even if you are sure you provided the correct care - and this may cause
you to lose your right to practise.
In short, the patient's nursing record provides a correct account of the treatment and care given
and allows for good communication between you and your colleagues in the eye care team.
Keeping good nursing records also allows us to identify problems that have arisen and the action
taken to rectify them.

‘Keeping good nursing records allows us to identify problems that have arisen and the
action taken to rectify them’

In this article, we discuss how to be effective in your record keeping and how to maintain the
high standards required.

Who is responsible for record keeping?


Anyone on the nursing team who provides patient care can contribute to record keeping.
However, if you are a qualified or senior nurse supervising unqualified colleagues, you should
assume responsibility for providing guidance on documentation.

What should go into a patient's nursing record?


The nursing record is where we write down what nursing care the patient receives and the
patient's response to this, as well as any other events or factors which may affect the patient's
wellbeing. These ‘events or factors’ can range from a visit by the patient's relatives to going to
theatre for a scheduled operation.

If you are in any doubt about what to write down, it may be useful to ask yourself the following:
“If I was unable to give a verbal handover to the next nursing team, or the next shift, what would
they need to know in order to continue to care for my patients?” You want to ensure that the
patient's care is not affected by the changeover of nursing staff.

How to keep good nursing records


The patient's record must provide an accurate, current, objective, comprehensive, but concise,
account of his/her stay in hospital. Traditionally, nursing records are hand-written. Do not
assume that electronic record keeping is necessary.

 Use a standardised form. This will help to ensure consistency and improve the quality of
the written record. There should be a systematic approach to providing nursing care (the
nursing process) and this should be documented consistently. The nursing record should
include assessment, planning, implementation, and evaluation of care.
 Ensure the record begins with an identification sheet. This contains the patient's personal
data: name, age, address, next of kin, carer, and so on. All continuation sheets must show
the full name of the patient.
 Ensure a supply of continuation sheets is available.
 Date and sign each entry, giving your full name. Give the time, using the 24-hour clock
system. For example, write 14:00 instead of 2 pm.
 Write in dark ink (preferably black ink), never in pencil, and keep records out of direct
sunlight. This will help to ensure they do not fade and cannot be erased.
 On admission, record the patient's visual acuity, blood pressure, pulse, temperature, and
respiration, as well as the results of any tests.
 State the diagnosis clearly, as well as any other problem the patient is currently
experiencing.
 Record all medication given to the patient and sign the prescription sheet.
 Record all relevant observations in the patient's nursing record, as well as on any charts,
e.g., blood pressure charts or intraocular pressure phasing charts. File the charts in the
medical notes when the patient is discharged.
 Ensure that the consent form for surgery, signed clearly by the patient, is included in the
patient's records.
 Include a nursing checklist to ensure the patient is prepared for any scheduled surgery.
 Note all plans made for the patient's discharge, e.g., whether the patient or carer is
competent at instilling the prescribed eye drops and whether they understand details of
follow-up appointments.

Patients' records must provide an accurate account of their hospital stay. SOUTH AFRICA

Elmien Wolvaardt Ellison

Writing tips
 Ensure the statements are factual and recorded in consecutive order, as they happen. Only
record what you, as the nurse, see, hear, or do.
 Do not use jargon, meaningless phrases, or personal opinions (e.g., “the patient's vision
appears blurred” or “the patient's vision appears to be improving”). If you want to make a
comment about changes in the patient's vision, check the visual acuity and record it.
 Do not use an abbreviation unless you are sure that it is commonly understood and in
general use. For example, BP and VA are in general use and would be safe to use on
records when commenting on blood pressure and visual acuity, respectively.
 Do not speculate, make offensive statements, or use humour about the patient. Patients
have the right to see their records!
 If you make an error, cross it out with one clear line through it, and sign. Do not use
sticky labels or correction fluid.
 Write legibly and in clear, short sentences.
 Remember, some information you have been given by the patient may be confidential.
Think carefully and decide whether it is necessary to record it in writing where anyone
may be able to read it; all members of the eye care team, and also the patient and
relatives, have a right to access nursing records.

Looking after nursing records


Keep the nursing records in a place where they can be accessed easily; preferably near to where
the nursing team meet at shift change times. This will ensure that records are available for
handover sessions and also that they are easily accessible to the rest of the eye care team. The
handover may take place with the patient present, if appropriate. Indeed, nursing records can
only be accurate if patients have been involved in decision making related to their care.

File the nursing records in the medical notes folder on discharge. Ensure that the whole team
knows if nursing records are stored elsewhere.

How can nursing records contribute to VISION 2020?


Accurate records will contain observations of clinical outcomes, for example, how an elderly
patient has benefited from his or her cataract operation or how skilled the patient is at instilling
eye drops before discharge. Such information can be used in clinical audit and reports on clinical
activity. This contributes to research and performance data which can be used to monitor
improvement in service delivery and outcomes, all of which ultimately contributes to VISION
2020. It is not only medical notes that are important; well-written nursing records will provide
qualitative comment on treatment outcomes.

Contributor Information
Sue Stevens, Former Nurse Advisor, Community Eye Health Journal, International Centre for
Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E
7HT, UK.

Dianne Pickering, Nurse Advisor, Community Eye Health Journal; Registered General Nurse,
Norfolk and Norwich University Hospital, UK. ku.shn.hunn@gnirekcip.ennaid.

Nursing Documentation
 Introduction

Aim

Definition of Terms

Process

Special Considerations

Companion Documents

Evidence Table
Introduction
Nursing documentation is essential for good clinical communication. Appropriate legible
documentation provides an accurate reflection of nursing assessments, changes in
conditions, care provided and pertinent patient information to support the
multidisciplinary team to deliver great care. Documentation provides evidence of care
and is an important professional and medico legal requirement of nursing practice.

Aim
To provide a structured and standardised approach to nursing documentation for
inpatients. This will ensure consistency across the RCH and improve clinical
communication.

Definition of Terms
Documentation: encompasses all written and/or electronic entries reflecting all aspects
of patient care communicated, planned recommended or given to that patient.

‘End of shift’ progress notes: nursing documentation written as a summary at the end or
towards the end of shift.

‘Real time’ progress notes: nursing documentation written in a timely manner during
the shift.

ISBAR: (Identify, Situation, Background, Assessment, Recommendation) framework for


clinical communication

Admission assessment: Comprehensive nursing assessment including patient history,


general appearance, physical examination and vital signs completed at the time of
admission.

Shift assessment: Concise nursing assessment completed at the commencement of each


shift or if patient condition changes at any other time during your shift.

Process
Nursing documentation will support the process;

1. Patient assessment,
2. Plan of care
3. Real time progress notes
Patient assessment
An admission assessment is completed and documented on the Nursing Admission
(MR850/A) as per Nursing assessment guideline.

At the commencement of each shift, following handover, patient introductions and safety
checks, a ‘commencement of shift assessment’ is completed as outlined in the Nursing
assessment guideline. These assessments are documented on the Patient Care Plan (MR
856/A). If there is more information gained from this assessment than space allowed,
additional information is documented in the progress notes. In Neonates (Butterfly) and
PICU (Rosella), commencement of shift assessments are completed in progress notes.

Plan of Care
Taking into consideration the patient assessment, clinical handover, previous patient
documentation and verbal communication with the patient and family the plan of care for
the shift is made and documented on the Patient Care Plan (MR 856/A). The plan should
be negotiated with patients’ and their carers to ensure clear expectations of care,
procedures, investigations and discharge, are set early in the shift. The plan of care
should align with information on the patient journey board.

Real time Progress Notes


Documentation is captured in the patient’s progress notes in ‘real time’ throughout the
shift instead of a single entry end of shift.

Any relevant clinical information is entered in a timely manner such as;

o Abnormal assessment, eg. Uncontrolled pain, tachycardic, increased WOB, poor


perfusion, hypotensive, febrile etc.
o Change in condition, eg. Patient deterioration, improvements, neurological status,
desaturation, etc.
o Adverse findings or events, eg. IV painful, inflamed or leaking requiring removal,
vomiting, rash, incontinence, fall, pressure injury; wound infection, drain losses,
electrolyte imbalance, +/-fluid balance etc.
o Change in plan (Any alterations or omissions from plan of care on patient care
plan) eg. Rest in bed, increase fluids, fasting, any clinical investigations (bloods,
xray), mobilisation status, medication changes, infusions etc.
o Patient outcomes after interventions eg. Dressing changes, pain management,
mobilisation, hygiene, overall improvements, responses to care etc.
o Family centred care eg. Parent level of understanding, education outcomes,
participation in care, child-family interactions, welfare issues, visiting
arrangements etc.
o Social issues eg. Accommodation, travel, financial, legal etc.

Progress note entries should include nursing content and evidence of critical thinking.
That is, they should not simply list tasks or events but provide information about what
occurred, consider why and include details of the impact and outcome for the particular
patient and family involved.

All entries should be accurate and relevant to the individual patient. Generic
information such as ‘ongoing’ is not useful.
Duplication should be avoided. Blanket statements about information recorded on other
medical records are not useful, for example, ‘medications given as per Medication chart’.
Professional nursing language is used for all entries to clearly communicate assessment,
plan and care provided. For example; ‘TLC’ does not reflect nursing care.
Abbreviations should be consistent with RCH standards.

Structure

The structure of each progress note entry should follow the ISBAR philosophy with a
focus on the four points of Assessment, Action, Response and Recommendation.

Identify. Positive patient identification and ensure details are correct on documents. Write
the current date, time and “Nursing” heading. The first entry you make each shift must
include your full signature, printed name and designation. Subsequent entries on the same
shift must be identified with date/time and ‘Nursing’ but may be signed only.

Situation & Background. not often required for ‘real-time’ entries. Maybe relevant for
admission notes or transfer from one dept to another.

Assessment. What does the patient look like? What has happened?

Action. What have you done about it? Interventions, investigations, change in care or
treatment required?

Response. How has the patient responded? What has changed? Improvement or
deterioration?

Recommendation. What is your recommendation or plan for further interventions or


care?

Examples of real time progress note entries

2/7/2014
09:40 NURSING. Billie is describing increasing pain in left leg. Pain score increased.
Paracetamol given, massaged area with some effect. Education given to Mum at the
bedside on providing regular massage in conjunction with regular analgesia. Continue
pain score with observations.
10:15 NURSING. Episode of urinary incontinence. Billie quite embarrassed. Urine bottle
placed at bedside.
14:30 NURSING. Routine bloods for IV therapy taken, lab called- low Na+. Medical
staff notified, maintenance fluids reduced to 5ml/hr. Repeat bloods in 6/24. Encourage
oral fluids and diet, if tolerated, IV can be removed.

Special Considerations
Critical care areas (Rosella & Butterfly).
In these clinical areas, the ‘commencement of shift’ patient assessment and plan of care
should be documented in the progress notes. Real-time progress notes are captured in
either the clinical comments section of the observation charts or the in progress notes.
Nursing Admissions are completed:

o Neonates (Butterfly) – Neonatal Unit Nursing Admission/History, (MR 851/A)


o Paediatric Intensive Care (Rosella) –PICU Management Plan, (MR 855/A)

Emergency.
The Emergency Department have department specific documentation tools, however
progress notes should follow the structure as detailed above.

Theatres.
The Operating Suite uses ORMIS (Operating Room Management Information System) to
record all surgical procedures
http://www.rch.org.au/surgery/local_procedures/ORMIS_Nursing_Intra_Operative_Docu
mentation/

Banksia.
The patient population in this unit requires assessment that is continuous throughout the
shift and so commencement of shift assessment and plan of care are incorporated into
progress notes.

Nursing Admission - Day stay.


May be used for patients staying less than 24hours in the areas of Day Medical Unit or
Day of Surgery.

Wallaby Ward.
Commencement of shift assessments are completed verbally within two hours of the shift
commencing by contacting families.

o “How is your child?”


o “Is there any change with your child since yesterday?”
Verbal commencement of shift assessments along with ABCDF, risk, OH &S and
medication assessments are documented on the Patient care plan (MR 856/A).

All plans for care are documented on the Patient care plan and real-time progress notes
should follow the structure as detailed above.

Less than 24hr Admissions (Oximeters + Ambulatory Blood Pressure Monitoring)


Commencement of shift assessment and real-time progress notes are documented.
Note: do not require Nursing Admission Forms.

CVC Care
Commencement of shift assessment, Patient care plan and real-time progress notes are
documented.
Note: do not require Nursing Admission Forms.

HOW TO WRITE AN INSIDENT REPORT


Incident reporting is the responsibility of all team members. This article will provide you with a
clear overview of writing an effective incident report, what to include and how to describe the
situation objectively.

It is important to ensure that prompt reporting of an incident, as well as appropriate corrective


action, take place. Time lines for both will also be legally imposed. You should therefore
understand that the requirement of incident reporting in your workplace should result in
improvements in your practice environment.

Related:
Online CPD for Nurses

Incident Reports and Legal Jeopardy


This lecture reviews the critical principles that underpin the preparation of incident reports, but
more importantly, describes how they can be used as instruments for positive change. Learn
more.

Overview
Incident reports comprise two aspects. First, there is the actual reporting of any particular
incident (this may be something affecting you, your patient or other staff members), and the
relevant corrective action taken. Secondly, information from incident reports is analysed to
identify overall improvements in the workplace or service.

You should be familiar with, and follow, incident reporting procedures in your workplace. The
following tips are provided to help this process.
What is included in an incident report?
 The name of the person(s) affected and the names of any witnesses to an incident
 Where and when the incident occurred
 The events surrounding the incident
 Whether an injury occurred as a direct result of the incident
 The response and corrective measures that were taken

It should be signed and dated prior to handing it in to the appropriate person, such as a
supervisor.

SEE ALSO: How to cope when you become too emotionally involved

What situations should be reported? Examples include:


 Injuries – physical such as falls and needle sticks, or mental such as verbal abuse
 Errors in patient care and medication errors
 Patient complaints, any episodes of aggression
 Faulty equipment or product failure (such as running out of oxygen)
 Any incident in which patient or staff safety is compromised.

You should keep the following points in mind when


documenting an incident:
Use objective language

Write what was witnessed and avoid assigning blame; write only what you witnessed and do not
make assumptions about what occurred.

 Have the affected person or witnesses tell you what happened and use direct quotations
 Ensure that the person who witnessed the event writes the report

Report in a timely manner

Complete your report as soon as the incident occurs, or as soon as is feasible afterwards. Never
try to cover up or hide a mistake! Nurses practice within a Code of Conduct. Detailed discussion
is essential, especially thorough communication in aged care settings where residents remain in
the nurse's care for longer periods of time.

By following these simple tips, you will help to keep your patients safe and will also protect
yourself.