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Expert spotlight: Get nursing documentation on track in your facility

Nurse Leader Weekly, November 3, 2008

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This week, consider some expert advice from Patricia A. Duclos-Miller, RN, MS, NE-BC, associate professor in nursing at Capital Community College in Hartford, CT, to help your nurses stay on target when documenting.

Q: What strategies can we implement in our facility to ensure our staff nurses document their nursing notes each shift?

A: First, look at your overall documentation system and requirements. Do staff members need to document every shift or do they only document when there is a change in a patient's condition? When reviewing a medical record, federal and state auditors tend to look for how and when nurses intervene when there is a change in the status or condition of the patient.

Second, look at what is being documented. Is there a format that would assist staff in staying focused on what is most important in their progress notes? Consider using the focus charting method. Patient concerns are usually identified during the admission assessment or reassessment while being hospitalized. In focus charting, the identified concern is the "focus" of the narrative note. This methodology of documentation assists the writer in remaining on task by documenting what the data is, what action the nurse took for the note's problem/focus, and how the patient responded. The nursing tasks and assessment data are documented on flow sheets. Therefore, the progress notes reflect analysis, interventions, and conclusions based on the data.

Third, peer-to-peer chart audits can be powerful tools to motivate staff to change. Everyone perceives their documentation as concise, timely, and relevant, but a second set of eyes may not view them that way. Building a user-friendly audit tool and sharing the results has worked in many facilities. The staff will want to see how well they are doing and move forward in compliance as a whole. 

Editor's note: Do you have a question for our experts? Email your queries to editor Keri Mucci at kmucci@hcpro.com and see your name in print next week! In the meantime, head over to our Web site and view a growing collection of advice from our experts.

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