DocumentationDocumentation

Language is our primary method Language is our primary method of of

Communication!Communication!

2 Methods of Communicating2 Methods of Communicating

Documentation: anything written or printed Documentation: anything written or printed that is relied on as a record – a record of that is relied on as a record – a record of observations and care used by all HCPobservations and care used by all HCP

Reporting: communication of information Reporting: communication of information to another – may be written or oral to another – may be written or oral

GoalGoal Good, effective, error-free patient careGood, effective, error-free patient care Accomplished through accurate historical Accomplished through accurate historical

record keeping, medical-legal record keeping, medical-legal documentation, & transfer of information documentation, & transfer of information among the health care teamamong the health care team

RN’s are RN’s are legally & ethicallylegally & ethically required to required to practice in accordance with the CRNNS practice in accordance with the CRNNS Standards for Nursing Practice: a nurse is Standards for Nursing Practice: a nurse is expected to record & maintain expected to record & maintain documentation that is clear, timely, documentation that is clear, timely, accurate, reflective of observations, accurate, reflective of observations, permanent, legible, & chronological.permanent, legible, & chronological.

““not documented – not done”not documented – not done” Without clear inclusive documentation, it Without clear inclusive documentation, it

can appear that the patient receiving the can appear that the patient receiving the best care may have received none.best care may have received none.

Language that is used for medical & Language that is used for medical & nursing documentation & verbal report is nursing documentation & verbal report is very different than what most people use very different than what most people use in daily conversation.in daily conversation.

Over the year, as you complete various Over the year, as you complete various assessments & document your findings on assessments & document your findings on your lab sheets, you will build language your lab sheets, you will build language skills that are necessary to clearly skills that are necessary to clearly document & verbally communicate with document & verbally communicate with other nursesother nurses

Rules of English grammar ensure that you Rules of English grammar ensure that you present complete thoughts & complete present complete thoughts & complete sentencessentences

Efficient use of language in nursing is Efficient use of language in nursing is similar to shorthandsimilar to shorthand

Discard the rules of English grammar Discard the rules of English grammar because it is time-consuming & frequently because it is time-consuming & frequently not necessary to use complete sentencesnot necessary to use complete sentences

Want to be brief & complete in your Want to be brief & complete in your documentationdocumentation

Hard to let go of formal sentence structure Hard to let go of formal sentence structure because we have been taught that clear because we have been taught that clear thoughts depend on a complete sentence.thoughts depend on a complete sentence.

Good documentation should provide clear Good documentation should provide clear information that leaves little room for information that leaves little room for interpretation interpretation

Words that have more than one Words that have more than one meaningmeaning

You will use words that have everyday You will use words that have everyday meaning, as well as specific technical meaning, as well as specific technical meaning in nursing & the medical fieldmeaning in nursing & the medical field

Mole Mole small mammal; undercover spysmall mammal; undercover spy Small raise growth on skinSmall raise growth on skin

AppendixAppendix Supplemental section at the end of a bookSupplemental section at the end of a book Appendage on the small bowelAppendage on the small bowel

EliminateEliminate Get rid ofGet rid of Expel waste material from the bodyExpel waste material from the body

RunRun To move rapidly on footTo move rapidly on foot Deliver fluids or meds through IVDeliver fluids or meds through IV

BeatBeat Hit repeatedlyHit repeatedly PulsationPulsation

PrimePrime best, firstbest, first Run fluid through a tube to get rid of the airRun fluid through a tube to get rid of the air

DressDress Put on clothes; one piece style of women’s Put on clothes; one piece style of women’s

clothingclothing Apply cover to protect a woundApply cover to protect a wound

Abbreviations Abbreviations

Need to become fluent in acceptable Need to become fluent in acceptable abbreviationsabbreviations

List in your student handbookList in your student handbook Also be aware of your work environmentAlso be aware of your work environment

““tx” could mean treatment in a clinic or tx” could mean treatment in a clinic or traction in an orthopedic unittraction in an orthopedic unit

Can not state Can not state GOODGOOD or orNORMAL NORMAL

in your findingsin your findings

BilateralBilateralversus versus

Symmetrical Symmetrical

Avoid Avoid appears, seems, or appears, seems, or apparentlyapparently

These suggest that the nurse does not These suggest that the nurse does not know the facts & shows uncertainty know the facts & shows uncertainty

““Patient appears to be sleeping”. = incorrectPatient appears to be sleeping”. = incorrect

““Patient resting with eyes closed, RR 16 bpm”. = correctPatient resting with eyes closed, RR 16 bpm”. = correct

Subjective versus ObjectiveSubjective versus Objective

Objective – clear, descriptive content with Objective – clear, descriptive content with measurable parameters. As a nurse, you measurable parameters. As a nurse, you will use critical thinking to assess available will use critical thinking to assess available data, problem solve & then record the data, problem solve & then record the assessment data in professional, assessment data in professional, minimally biased languageminimally biased language

Include patient’s subjective remarks in Include patient’s subjective remarks in direct quotation marksdirect quotation marks

BiasBias Be careful when documenting client’s Be careful when documenting client’s

personal health habits to avoid bias on the personal health habits to avoid bias on the part of the health care professional part of the health care professional

For example – grossly obeseFor example – grossly obese Carefully select language in both written Carefully select language in both written

record & in communicating with co-record & in communicating with co-workers to minimize misinformation & bias workers to minimize misinformation & bias

Bias is an inclination or preference that Bias is an inclination or preference that interferes with impartial judgment interferes with impartial judgment (prejudice)(prejudice)

Recording a patient’s pain – each person Recording a patient’s pain – each person has an individual response or tolerance of has an individual response or tolerance of pain. Use numerical pain measurement pain. Use numerical pain measurement scales to interpret each person’s response scales to interpret each person’s response to pain. Be careful to avoid judgment or to pain. Be careful to avoid judgment or bias in interpreting pain levelsbias in interpreting pain levels

Watch judgmental or inflammatory Watch judgmental or inflammatory language spoken to or about a patientlanguage spoken to or about a patient

For example – compliant, uncooperative, For example – compliant, uncooperative, angry, sweet, arrogant – these are poor angry, sweet, arrogant – these are poor descriptors that can have a heavy impactdescriptors that can have a heavy impact

If using negative words – noncompliant, If using negative words – noncompliant, refused, denied, hostile, aggressive, etc. – refused, denied, hostile, aggressive, etc. – be sure to use supporting be sure to use supporting factualfactual data to data to avoid judgmental reactionsavoid judgmental reactions

Other than quoted remarks, subjective Other than quoted remarks, subjective comments do not belong in your nursing comments do not belong in your nursing notes.notes.

Your own feelings are not relevant & can Your own feelings are not relevant & can be inflammatorybe inflammatory

Spelling Spelling

Complete & sequential recording of Complete & sequential recording of events, legibility, & correct spelling are events, legibility, & correct spelling are necessary for the professional necessary for the professional presentation of your documentationpresentation of your documentation

If you are a frequent or chronic misspeller, If you are a frequent or chronic misspeller, learn to use a dictionary!!learn to use a dictionary!!

Look at the following misspelled words - Look at the following misspelled words -

CronicCronic EmmissisEmmissis DarrehaDarreha Fuzzy babyFuzzy baby DuaghterDuaghter OderOder ApearedApeared HystariaHystaria flemmflemm

Re-read your documentationRe-read your documentation

Read your notes to see if you have Read your notes to see if you have recorded what you wanted to sayrecorded what you wanted to say

A good idea to even read your charting out A good idea to even read your charting out loud - do your words match your intent, loud - do your words match your intent, what is relevant to the patient’s care & what is relevant to the patient’s care & outcome, what nursing actions do you outcome, what nursing actions do you need to relate, avoid bias, do not be vague need to relate, avoid bias, do not be vague or inconsistent, include what the patient or inconsistent, include what the patient states in their own wordsstates in their own words

Actual examples of charting:Actual examples of charting:

The skin is moist & dryThe skin is moist & dry She stated she had been constipated for most She stated she had been constipated for most

of her lifeof her life Occasional, constant, infrequent headachesOccasional, constant, infrequent headaches Patient was alert & unresponsivePatient was alert & unresponsive The patient refused autopsyThe patient refused autopsy The patient has no previous history of suicidesThe patient has no previous history of suicides The lab test indicated abnormal lover functionThe lab test indicated abnormal lover function

Acceptable Documentation for Acceptable Documentation for Skin Skin

Skin: pink-tan color, even pigmentation Skin: pink-tan color, even pigmentation with no nevi. Warm to touch, dry, smooth, with no nevi. Warm to touch, dry, smooth, & even. Elastic turgor, no lesions& even. Elastic turgor, no lesions

Hair: even distribution, thick texture, no Hair: even distribution, thick texture, no lesions or pest inhabitantslesions or pest inhabitants

Nails: nail beds pink with prompt cap refill, Nails: nail beds pink with prompt cap refill, no clubbingno clubbing

Another ExampleAnother Example

Skin pink, warm, dry & elastic. No lesions Skin pink, warm, dry & elastic. No lesions or excoriations noted. Old appendectomy or excoriations noted. Old appendectomy scar RLQ 10cm long. Scattered freckles scar RLQ 10cm long. Scattered freckles noted on nose & cheeks. Hair brown, noted on nose & cheeks. Hair brown, shoulder length, clean & shiny. Nails form shoulder length, clean & shiny. Nails form 160 angle at base, smooth & firm. Nail 160 angle at base, smooth & firm. Nail beds pink, without clubbingbeds pink, without clubbing

Example of Head & Neck Example of Head & Neck DocumentationDocumentation

Head: normocephalic, no lumps, lesions, Head: normocephalic, no lumps, lesions, or tendernessor tenderness

Face: symmetric features, no drooping, Face: symmetric features, no drooping, weakness, or involuntary movementsweakness, or involuntary movements

Neck: full ROM, no pain. Symmetric, with Neck: full ROM, no pain. Symmetric, with no masses. Lymph nodes nonpalpable. no masses. Lymph nodes nonpalpable. Trachea midline, thyroid nonpalpable, Trachea midline, thyroid nonpalpable, smooth movement. No bruit smooth movement. No bruit

Another exampleAnother example Head symmetrically round, hard, & smooth Head symmetrically round, hard, & smooth

without lesions or bumps. Face oval, without lesions or bumps. Face oval, smooth, & symmetric. Temporal pulse smooth, & symmetric. Temporal pulse regular & 2+ bil. Neck symmetric with regular & 2+ bil. Neck symmetric with centered head position. Smooth, controlled, centered head position. Smooth, controlled, full range of motion of neck. Thyroid gland full range of motion of neck. Thyroid gland nonvisible but palpable when swallowing. nonvisible but palpable when swallowing. Trachea midline. Lymph nodes nonpalpable Trachea midline. Lymph nodes nonpalpable except for a few deep cervical nodes, except for a few deep cervical nodes, round, nontender, movable & < 1cm bilat. round, nontender, movable & < 1cm bilat.