Hey Boo Hey!
Let’s Talk About Nursing Documentation
I remember starting out as an LPN, wondering what to document and when to do it.
Nobody teaches you this in nursing school—it’s one of those things you learn on the job, usually the hard way.
I’ll be honest, my early documentation was vague because I didn’t know any better.
Over time, as I moved into different roles, from nurse to risk manager to educator, I realized just how important clear, concise documentation is—not just for patient care, but to protect yourself, too.
Now, my goal is to teach nurse leaders and staff what to document, how to document, and why it matters. Let’s break it down.
Why Documentation Matters
Patient/resident Safety: Your notes ensure continuity of care. If you don’t chart it, how will the next nurse know what’s going on?
Legal Protection: If it’s not documented, it didn’t happen. Trust me, vague or missing documentation can come back to haunt you in a legal situation.
Your Reputation: Your documentation represents you. When someone reads your notes, it should tell a clear story about what happened, what you did, and how you followed up.
What to Document
Focus on anything abnormal or outside the patient’s baseline:
Changes in behavior or functional status
New medications, antibiotics, or treatments (e.g., Foley catheters, IVs, tube feeding)
Missed medications or treatments
Any accidents or falls
Your documentation should include:
Who: The patient and anyone involved.
What: The event, intervention, or outcome.
When: Time and date of the occurrence.
Where: The location, if relevant.
Why: The reason for the event or intervention.
How: How you addressed it and what steps you’ll take to prevent it from happening again.
Common Documentation Pitfalls
Vague Notes: Writing "will continue to monitor" without explaining what you're monitoring or how you're doing it is not helpful.
Negative Notes Without Action: If you identify an issue but don’t document what you did about it, it’s incomplete. For example, don’t just write “patient had a fall.” Document the intervention, notification, and follow-up.
Late or Missing Entries: Chart in real-time whenever possible. If you wait until the end of your shift, you risk forgetting details.
Pro Tips for Better Documentation
Tell a Story: Your notes should have a beginning (what happened), middle (what you did), and end (the outcome and follow-up).
Know the Difference Between Subjective and Objective:
Subjective: What the patient or resident tells you (e.g., “I’m in pain”).
Objective: What you observe or measure (e.g., “BP 150/90, patient grimacing, pain 8/10”).
Be Clear and Concise: Use simple, professional language. Avoid jargon or unapproved abbreviations.
Practice During Interviews: I’ve started including documentation exercises in interviews for new hires. This creates an opportunity to teach early and set expectations.
Building a Documentation Culture
Strong documentation isn’t just an individual skill—it’s a team effort. As a leader, I review notes during morning clinical meetings to catch gaps early.
For example, if a patient starts a new antibiotic or has a fall, I’ll ensure it’s added to the 24-hour follow-up tool, so everyone knows to chart on it and follow up.
Remember, documentation should always answer these two questions:
What happened?
What did you do about it?
Final Thoughts
Documentation can feel overwhelming, but it doesn’t have to be. Keep it simple, clear, and concise.
Use the “5 Ws” to guide you and remember to document in real-time whenever possible.
We’ve all had moments where we second-guessed our notes or wished we’d added more detail. That’s okay—it’s part of learning. But the more intentional you are, the stronger your documentation will become.
What’s one tip you’ll start using in your charting? Drop it in the comments—I’d love to hear from you! ❤️
Lead with Love ❤️
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