Essential Components of Complete Nursing Documentation
The primary purpose of nursing documentation must be to support patient care and improve clinical outcomes through enhanced communication, with documentation emphasizing clarity, brevity, and attention to the needs of other readers including patients. 1
Core Documentation Standards
Good documentation is a fundamental component of high-quality care, and professional standards should keep the best elements of paper-based documentation without duplicating its inefficiencies and limitations. 1
The Patient's Story
- The clinical record must include the patient's story in as much detail as is required to retell the story. 1
- When permitted by regulations, documentation may contain entries by the patient as well as other care team members. 1
- The narrative should capture symptoms, concerns, and the patient's perspective in sufficient detail. 2
Structured Documentation Using the Nursing Process
Progress notes should follow the SOAP format (Subjective, Objective, Assessment, Plan) to capture initial visits and monitor follow-up care effectively. 2
The nursing process must include:
- Assessment data: Document measurable clinical findings including vital signs, physical examination findings, and relevant test results. 2
- Nursing diagnoses: Identify patient problems based on assessment findings. 3, 4
- Care aims/goals: Establish prioritized goals with intervention strategies for risk reduction. 2
- Planned interventions: Document specific nursing interventions planned to address identified problems. 3, 4
- Progress and outcome evaluations: Include ongoing evaluation of patient response to interventions. 3
- Prognosis: Document when relevant, particularly for serious conditions or when discussing goals of care. 2
Documentation Best Practices
Clarity and Accuracy
- Document observations completely, concisely, and accurately to support information reuse across the care team. 2
- Avoid pejorative language in descriptions of patients, patient behaviors, and findings. 1
- Ensure legibility of all nursing reports. 3
- Document the treatment plan and communicate it interactively with patients and appropriate family members. 2
Templates and Macros
- When used appropriately, macros and templates may be valuable in improving completeness and efficiency of documentation, particularly for standardized terminology such as review of systems and physical examination findings. 1
- Templates should not replace critical thinking or individualized patient assessment. 1
Review of Prior Documentation
- The EHR should facilitate thoughtful review of previously documented clinical information, including longitudinal history, care plans, and prior physical examination findings. 1
- When data are pulled from another location in the chart, the source must be indicated and supplemented by appropriately abstracted narrative content. 1
Critical Pitfalls to Avoid
Copy/Paste Misuse
- Avoid excessive copy-forward of prior notes without editing, as this propagates errors and reduces clinical utility. 2
- The "copy/paste" function where entire notes are copied can result in factual errors, old dates, and inaccurate vital signs being passed from note to note. 1
- When using "review/edit and/or attest, and then copy/forward" of specific prior history or findings, ensure accuracy and add value to current documentation. 1
Documentation Gaps
- Research shows 95% of patient records have inadequate documentation of nursing interventions, representing the lowest accuracy scores across all documentation domains. 3
- Less than one-fifth of nurses document nursing history and outcomes for all or most patients. 5
- Nursing diagnoses, goals, and discharge summaries are rarely documented. 5
Electronic Health Record Considerations
Structured Data Capture
- Structured data should be captured only where useful for care delivery or essential for quality assessment or reporting. 1, 2
- EHR systems should support "write once, reuse many times" with embedded tags identifying the original source of information. 2
- Use standardized nursing terminology (such as Clinical Care Classification System) to enable continuity between patient assessments and Plans of Care. 6
System Design Requirements
- Electronic health records should maintain the integrity of the patient narrative while allowing for structured data capture when necessary. 7
- The amendment process should be clearly documented with appropriate metadata including author information, authentication details, timestamps, and document status. 7
- Amendments should never replace original documentation but should be added as supplementary information. 7
Special Documentation Requirements
Do-Not-Attempt-Resuscitation Orders
Progress notes accompanying DNR orders must include: 2
- Prognosis
- Description of discussions with family and medical team
- Documented expressed wishes of patient and family decision-makers
- Notation of unresolved issues
- Recommendations from treating team and consultants
Patient Access to Records
- Patient access to progress notes may improve both patient engagement and quality of care. 1
- Documentation should be written with the understanding that patients will read their records. 1
- Increased transparency requires avoidance of pejorative language and increased clarity in care plans. 1
Ongoing Requirements
Training and Education
- Effective and ongoing EHR documentation training of clinical personnel should be a continuous process. 1
- Health care professionals need further training in documenting patient care according to the nursing process and in using standardized terminology to increase patient safety. 4
- Organizations should establish clear policies and procedures for documentation practices. 7