Nursing documentation or recording a patient’s medical history does not just promote effective and ethical practice, but it also serves as a manual for professional responsibility. For many years, documentation has been one of the primary links between healthcare professionals and patients. It defines the quality of care nurses provide.
With its crucial role in the industry, it is important that nurses should understand how documentations are presented. Whether it is paper-based or electronically generated, nursing documentation should be a part of every nurse’s role.
The Case Description:
Mr. James is a 57 year old gentleman admitted to room 224A two days ago for dehydration secondary to nausea and vomiting for three days. His sclera is slightly yellowed and his abdomen is distended and tender to palpation, especially in the upper right quadrant.
After two days of IV lasix therapy, he has 2+ edema in his lower extremities to the mid calf. (At admission he had 4+ edema up to the knee.) He complains of mild shortness of breath with moderate activity which he has experienced for several weeks. He has a history of alcohol abuse for 20 years, but denies any use in the past 6 months. He has no history of hepatitis or HIV. No history of drug abuse.
At 7:45 AM, Mr. James is complaining of increasing nausea. He has had no emesis for at least 5 hours, but feels (and fears) the need to vomit is becoming imminent. His last dose of anti-emetic (Tigan) was given at 4:30 AM and he states, "it only slightly relieved the nausea this time." It let him sleep for about two hours, but now he's "wide awake and very uncomfortable."
The orders for the Tigan are 200 milligrams (2ml) IM QID (four times a day), and is scheduled every six hours. It has only been a little over three hours since the last dose and is not due again until 10:30 AM. You tell him you will have to contact the MD for orders for something else. Mr. James is reluctant to have you do this. He thinks that if he can wait about 30 minutes, the MD is likely to be making his morning rounds. Mr. James wants to try to wait. He thinks he "can control the urge to vomit more it if he can get more comfortable in the bed."
A quick assessment of vital signs and his body systems reveals no change in condition. In assessing Mr. James, you determine that measures, which usually help him to reduce his nausea, include using a cold cloth on his forehead and one on the back of his neck. He is usually more comfortable lying on his left side, but is on his right side now because he's trying to comply with the need to alternate the pressure on his skin.
It has been about an hour that he's been on his right side. Turning can increase his nausea, but doing so slowly may be OK. You assist him to slowly turn and find a more comfortable position. You place the cold cloths on his forehead and the back of his neck, and he reports feeling "much better already." Slow deep breaths also help him to relax, as well as minimizing distractions such as the TV, lights and closing the door to the room. Pulling the curtains around his bed further isolate him and allow him to relax and concentrate on his slow breathing. In a few minutes, he is sleeping.
How to Document Your Assessment and Intervention
No matter what type of charting your facility uses from checklists to fully narrate discussions, you need to be sure to include the most important details. To tell the complete story accurately, you need to include "the 5 w's and an h."
There may be more than one way to answer or interpret these questions, but let's examine one way.
Whatever the format for your documentation, if you can make simple notes for yourself - the who, what, when, where, why and how, and make sure that you have included all of this information in your charting, then you will have accurately and adequately documented the episode.
Tip: Use patient statements to define subjective aspects. You could assume that because he was uncomfortable, he wasn't able to relax, and that it contributed to his increasing nausea. It is best, however, to quote the patient in such matters. Otherwise, state only the facts and what you observe.
Just as caring is an intergral part of our job, nursing documentation provides high impact on quality of care. That's why it is important to make this process comprehenve and efficient as much as possible.