When a patient's treatment plan is devised, the construct rests on the documentation and reporting of members of the treatment team. Without question, nursing documentation is part of professional practice. It is important to note that there are differences in how healthcare records are kept, depending upon the setting of practice. But the foundational principles of documentation for all nurses exist in every setting of practice.
So what is documentation?
Documentation is any written or electronically generated information about a client that describes client status, or the care or services provided to that client. Typically, in most health care arenas, patient documentation is now done electronically. The common charting format SOAPIE is ideal for a narrative patient record. SOAPIE, a systematic approach, details a goal-oriented nursing care plan in a note.
The nursing process begins with assessment, which is:
- Subjective - reports what the patient says;
- Objective - records what the nurse observes;
- Analysis - identifies a nursing diagnosis;
- Plan - describes nursing interventions;
- Implementation - records how those actions were carried out; and,
- Evaluation - reports the actual patient outcome or response.
When is Documentation Needed?
This will depend on the nature of the documentation. For instance, the time intervals for fall assessments and physical assessments will be once a shift (unless the patient is a high-risk for a fall). But, pain assessments are warranted at different time intervals: at the change of shift, when the patient leaves and returns from a procedure, at the time of admission, and at the time or discharge.
Oftentimes documentation is frowned upon because it steals time from the ability of all nurses to provide direct patient care. However, in essence, it provides direction and ensures quality in patient care. The time and effort that is devoted to documentation allows the patient's record to be pertinent, current, correct and complete. Without hesitation, in today's society, complete, thorough and accurate documentation is a matter of survival in professional nursing.
How effective are your documentation strategies as a nurse?