Standards and Guidelines for Quality Nursing Documentation Flashcards
Guidelines for Quality Documentation
Quality nursing documentation enhances efficient, individualized patient
care and has five important characteristics: factual, accurate, current,
organized, and complete. It is easier to maintain these characteristics in
your documentation if you continually seek to express ideas clearly and
succinctly by doing the following:
• Stick to the facts.
• Write in short sentences.
• Use simple, short words.
• Avoid the use of jargon or abbreviations.
Factual
A factual record contains clear descriptive, objective information about
what a nurse observes, hears, palpates, and smells. Avoid vague terms
such as appears, seems, or apparently. These words suggest you are stating
an opinion; they do not accurately communicate facts and do not inform
other caregivers about the details regarding the behaviors exhibited by a
patient. Objective data are obtained through direct observation and
measurement and include description of a patient’s behaviors, for
example, “BP 90/50, heart rate 115 and regular, patient diaphoretic and holding
both hands over abdominal dressing.” The only subjective data included in the
record are statements made by a patient. When recording subjective data,
document a patient’s exact words within quotation marks whenever
possible. Include objective data to support subjective data so that your
documentation is as descriptive as possible. For example, instead of
documenting “the patient seems anxious,” provide objective signs of anxiety
and document the patient’s statement about the feelings experienced:
“patient’s heart rate 110 beats/min, respiratory rate is slightly labored at 22
breaths/min, and patient states, ‘I feel very nervous.’”
Accurate
Using exact measurements establishes accuracy and helps you determine
whether a patient’s condition has changed in a positive or negative way.
For example, a description such as “Intake, 360 mL of water” is more
accurate than “Patient drank an adequate amount of fluid.” Documenting that
an abdominal incision is “Approximated, 5 cm in length without redness,
drainage, or edema” is more descriptive than “Large abdominal incision healing
well.”
Appropriate Use of Abbreviations in Health Care
Documentation
Use abbreviations carefully to avoid misinterpretation and promote
patient safety
Do Not Use Potential Problem Use Instead
U, u (unit) Mistaken for “0” (zero), the number “4”
(four) or “cc”
Write “unit.”
IU (International Unit) Mistaken for “IV” (intravenous) or the
number “10” (ten)
Write “International
Unit.”
Q.D., QD, q.d., qd (daily) Q.O.D., QOD, q.o.d., qod (every other day) Mistaken for each other Period after the Q mistaken for “I” and the “O” mistaken for “I” Write “daily.” Write “every other day.”
Trailing zero (X.0 mg)a Lack of leading zero (.X mg) Decimal point is missed Write X mg. Write 0.X mg.
MS MSO4 and MgSO4 Can mean morphine sulfate or magnesium sulfate Confused for one another Write “morphine sulfate.” Write “magnesium sulfate.”
All health care record entries should be dated and timed, and the author
of each entry must be clearly identified (TJC, 2018). Each entry in a
patient’s record must end with the caregiver’s full name or initials and
credentials/title/role such as “Jane Cook, RN.” If initials are used in a
signature, the full name and credentials/title/role of the individual needs
to be documented at least once in the health care record to allow others to
readily identify that individual. As a nursing student, enter your full name
and nursing student abbreviation, such as “David Jones, NS” or “David
Jones, SN.” The abbreviation for nursing student varies between NS for
nursing student or SN for student nurse. Include information about your
educational institution at the end of your signature when required by
agency policy.
Current
Document the following activities or
findings at the time of occurrence:
• Vital signs
• Pain assessment
• Administration of medications and treatments
• Preparation for diagnostic tests or surgery, including preoperative
checklist
• Change in patient’s status, treatment provided, and who was
notified (e.g., health care provider, manager, patient’s family)
• Admission, transfer, discharge, or death of a patient
• Patient’s response to treatment or intervention.Most health care agencies use military time, a 24-hour system that
avoids misinterpretation of AM and PM times
Organized
Documentation is more effective when notes are concise, clear and to the
point, and presented in a logical order.
Complete
Be sure the information within a recorded entry or a report is complete,
containing appropriate and essential information.
