Guidelines for Quality Documentation (Nursing)

by Samantha Rhea, MSN, RN

My Notes
  • Required.
Save Cancel
    Learning Material 3
    • PDF
      Slides Documentation.pdf
    • PDF
      Review Sheet Tips for Writing a Great Nursing Note Nursing.pdf
    • PDF
      Download Lecture Overview
    Report mistake

    00:01 All right. So next let's look at guidelines for quality documentation.

    00:05 So if you will look on the side of the screen that has all of these buzzwords, these are great things to keep in mind when you're documenting.

    00:13 For example, one characteristic is factual documentation.

    00:18 So if we look at incorrect documentation in this right, So when we're saying the patient seems like he's having pain.

    00:26 Okay, so you can see this is kind of using that opinion that we talked about earlier.

    00:30 This is not what we want for documentation.

    00:34 Now, if you look on the side that has correct documentation, we're saying the patient is grimacing and moaning when his leg is being touched.

    00:43 So let's look at the difference.

    00:45 So on the incorrect side, it says "seems".

    00:47 Again, there's that personal opinion.

    00:50 When we look at the correct side, as a nurse, we can see actually, objectively that the patient is grimacing.

    00:57 We can also use our senses that the patient is moaning.

    01:00 So these are more tangible data points to document for legal documentation.

    01:07 Next, let's look at accurate documentation.

    01:10 Seems like a no brainer, but here's where we get specific.

    01:14 So if I said there was a large amount of drainage, well, that's pretty subjective, right? What's large to you may not be large to me, so let's be specific.

    01:24 Therefore, we would chart something such as there was 500 mils of drainage.

    01:30 So see the difference here and that we have something tangible and specific.

    01:35 All right, so now let's look at a complete documentation.

    01:38 So on the incorrect side, we're talking about how the patient was taught how to check his blood sugar.

    01:44 Now let's look at the correct side, where it states patient was able to return demonstrate how to check his blood sugar.

    01:52 The difference here is on the correct side, the patient is-- it's already implied basically, that the patient is able to do their own blood sugar, but they're returned demonstrating to the nurse so we can evaluate if the patient knows how to do the procedure correctly.

    02:08 Next, let's look at current documentation.

    02:11 So on our incorrect side, we say that patient had a temperature at 0230 AM.

    02:17 On the correct side, let's compare.

    02:20 Patient had a temperature of 39.1 degrees Celsius at 0230 PM.

    02:27 So on the correct side, we're being specific and we're documenting the right time.

    02:33 And lastly, our documentation needs to be organized, such as when you read your nurse's note or other documentation, you should be able to follow it easily.

    02:43 On the incorrect side, for example, it states patient had altered mental status, stomach pain, and could not recall their name.

    02:52 So if you look at the correct side, we're gonna group some of this information together for a more organized pattern such as the patient had altered mental status, with the inability to recall his name and has complaints of stomach pain.

    About the Lecture

    The lecture Guidelines for Quality Documentation (Nursing) by Samantha Rhea, MSN, RN is from the course Patient Education, Documentation and Informatics (Nursing).

    Included Quiz Questions

    1. The client reports abdominal pain as sharp and rates it 8/10.
    2. The client seems to be pain-free and is playing on their phone.
    3. The client says, "The pain is really bad."
    4. The client looks much more comfortable than before the administration of morphine.
    1. The client is requesting a pregnancy test because her period is late for two weeks when she has a regular 28-day cycle. Today is November 21, 2020, and the client's first day of her last menstrual cycle was October 10, 2020. The client denies pain or other complaints.
    2. The client has stroke-like symptoms. Their blood pressure is 189/79, heart rate is 79, and respiratory rate is 22. They report the symptoms starting earlier this morning.
    3. The client has vomited a lot this morning. The vomit is green and has undigested food. The client has elevated blood pressure but denies pain.
    4. The client expressed suicidal ideation and anxiety. After administration of an antianxiety medication, the client looks more content and is eating something for the first time today.

    Author of lecture Guidelines for Quality Documentation (Nursing)

     Samantha Rhea, MSN, RN

    Samantha Rhea, MSN, RN

    Customer reviews

    5,0 of 5 stars
    5 Stars
    4 Stars
    3 Stars
    2 Stars
    1  Star