Accurate and timely documentation is a fundamental component of quality patient care. It ensures continuity, promotes coordination among providers, and creates a legal record of the care provided.
Documentation Principles
All entries must be:
Current & Timely: Document care immediately after it is provided.
Accurate & Factual: Record objective, measurable data without personal opinions.
Concise & Organized: Use clear, professional language and approved abbreviations.
Complete: Ensure all required fields are addressed.
Shift Start Protocol
Upon arrival, introduce yourself and check in at the nursing station.
Obtain your patient assignment and secure your login credentials for the Electronic Medical Record (EMR) system.
If credentials are not provided, it is your responsibility to request them from the nursing supervisor or director of nursing before beginning care.
CNA Documentation Standards
CNA documentation must include, but is not limited to, the following objective data:
Vital Signs: Blood pressure, pulse, respiration, temperature
Measurements: Height and weight
Intake and Output (I&O): All oral and IV fluids; urinary and other output
Nutrition: Appetite and percentage of food/fluid consumed
Elimination: Bowel movements (consistency, frequency)
Activities of Daily Living (ADLs): Bathing, hygiene, ambulation, positioning
Mental Status: Level of alertness and orientation
By adhering to these standards, you ensure patient safety and contribute effectively to the healthcare team.
LPN and RN Documentation Standards
As a nurse, your documentation should be current, accurate, organized, concise—and completed in a timely manner.
When you arrive at a facility to start your shift, you should introduce yourself and check in at the nursing station.
When given your assignment, make sure you receive the login information for their electronic medical records (EMR) system to maintain proper patient documentation.
If the login isn't provided, it's your responsibility to obtain the information from the nursing supervisor or director of nursing.
Nursing documentation is comprehensive and must include, but is not limited to, the following elements:
Comprehensive Assessments: The initial and ongoing head-to-toe nursing assessment, including systems review.
Subjective Data: Direct quotes from the patient or family regarding their concerns, symptoms, and history (e.g., "Patient states, 'I have a crushing pain in my chest.'").
Objective Data: Measurable, observable, and verifiable data including vital signs, physical exam findings, lab results, and diagnostic reports.
Assessment: Your clinical judgment and analysis of the subjective and objective data to identify problems and patient needs.
Plan: The outline of nursing interventions, medications, treatments, and goals designed to address the assessed needs.
Implementation: A detailed record of all nursing care provided, including patient education, treatments performed, and medications administered.
Evaluation: The patient's response to interventions and progress toward stated goals.
Medication Administration Record: Precise documentation of every medication administered, including drug, dose, route, time, and your signature. Must include documentation of medication refusal.
Verbal/Telephone Orders: Accurate transcription of the order, read-back verification to the prescriber, and timely cosigning per facility policy.
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