Clinical Guidelines (Nursing)

Nursing documentation

  • Note: This guideline is currently under review. 

    Introduction

    Aim

    Definition of Terms

    Process

    Special Considerations

    Companion Documents

    Evidence Table

    References

    Introduction

    Nursing documentation is essential for good clinical communication. Appropriate legible documentation provides an accurate reflection of nursing assessments, changes in conditions, care provided and pertinent patient information to support the multidisciplinary team to deliver great care. Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice.

    Aim

    To provide a structured and standardised approach to nursing documentation for inpatients. This will ensure consistency across the RCH and improve clinical communication.

    Definition of Terms

    Documentation: encompasses all written and/or electronic entries reflecting all aspects of patient care communicated, planned recommended or given to that patient.

    ‘End of shift’ progress notes: nursing documentation written as a summary at the end or towards the end of shift.

    ‘Real time’ progress notes: nursing documentation written in a timely manner during the shift.

    ISBAR: (Identify, Situation, Background, Assessment, Recommendation) framework for clinical communication

    Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.

    Shift assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift.

    Process

    Nursing documentation will support the process;

    1. Patient assessment,
    2. Plan of care
    3. Real time progress notes

    Patient assessment

    An admission assessment is completed and documented on the Nursing Admission (MR850/A) as per Nursing assessment guideline.

    Exceptions: See Special Considerations

    At the commencement of each shift, following handover, patient introductions and safety checks, a ‘commencement of shift assessment’ is completed as outlined in the Nursing assessment guideline. These assessments are documented on the Patient Care Plan (MR 856/A). If there is more information gained from this assessment than space allowed, additional information is documented in the progress notes. In Neonates (Butterfly) and PICU (Rosella), commencement of shift assessments are completed in progress notes.

    Plan of Care

    Taking into consideration the patient assessment, clinical handover, previous patient documentation and verbal communication with the patient and family the plan of care for the shift is made and documented on the Patient Care Plan (MR 856/A). The plan should be negotiated with patients’ and their carers to ensure clear expectations of care, procedures, investigations and discharge, are set early in the shift. The plan of care should align with information on the patient journey board.


    Real time Progress Notes

    Documentation is captured in the patient’s progress notes in ‘real time’ throughout the shift instead of a single entry at the end of shift.

    Any relevant clinical information is entered in a timely manner such as;

    • Abnormal assessment, eg. Uncontrolled pain, tachycardic, increased WOB, poor perfusion, hypotensive, febrile etc.
    • Change in condition, eg. Patient deterioration, improvements, neurological status, desaturation, etc.
    • Adverse findings or events, eg. IV painful, inflamed or leaking requiring removal, vomiting, rash, incontinence, fall, pressure injury; wound infection, drain losses, electrolyte imbalance, +/-fluid balance etc.
    • Change in plan (Any alterations or omissions from plan of care on patient care plan) eg. Rest in bed, increase fluids, fasting, any clinical investigations (bloods, xray), mobilisation status, medication changes, infusions etc.
    • Patient outcomes after interventions eg. Dressing changes, pain management, mobilisation, hygiene, overall improvements, responses to care etc.
    • Family centred care eg. Parent level of understanding, education outcomes, participation in care, child-family interactions, welfare issues, visiting arrangements etc.
    • Social issues eg. Accommodation, travel, financial, legal etc.

    Progress note entries should include nursing content and evidence of critical thinking. That is, they should not simply list tasks or events but provide information about what occurred, consider why and include details of the impact and outcome for the particular patient and family involved.


    All entries should be accurate and relevant to the individual patient. Generic information such as ‘ongoing’ is not useful.
    Duplication should be avoided. Blanket statements about information recorded on other medical records are not useful, for example, ‘medications given as per Medication Administration Record (MAR).
    Professional nursing language is used for all entries to clearly communicate assessment, plan and care provided. For example; ‘TLC’ does not reflect nursing care.
    Abbreviations should be consistent with RCH standards.

    Structure

    The structure of each progress note entry should follow the ISBAR philosophy with a focus on the four points of Assessment, Action, Response and Recommendation.

    Identify. Positive patient identification and ensure details are correct on documents. Write the current date, time and “Nursing” heading. The first entry you make each shift must include your full signature, printed name and designation. Subsequent entries on the same shift must be identified with date/time and ‘Nursing’ but may be signed only.

    Situation & Background. not often required for ‘real-time’ entries. Maybe relevant for admission notes or transfer from one dept to another.

    Assessment. What does the patient look like? What has happened?

    Action. What have you done about it? Interventions, investigations, change in care or treatment required?

    Response. How has the patient responded? What has changed? Improvement or deterioration?

    Recommendation. What is your recommendation or plan for further interventions or care?

    Examples of real time progress note entries

    2/7/2014
    09:40 NURSING. Billie is describing increasing pain in left leg. Pain score increased. Paracetamol given, massaged area with some effect. Education given to Mum at the bedside on providing regular massage in conjunction with regular analgesia. Continue pain score with observations.
    10:15 NURSING. Episode of urinary incontinence. Billie quite embarrassed. Urine bottle placed at bedside.
    14:30 NURSING. Routine bloods for IV therapy taken, lab called- low Na+. Medical staff notified, maintenance fluids reduced to 5ml/hr. Repeat bloods in 6/24. Encourage oral fluids and diet, if tolerated, IV can be removed.

    Special Considerations

    Critical care areas (Rosella & Butterfly).
    In these clinical areas, the ‘commencement of shift’ patient assessment and plan of care should be documented in the progress notes. Real-time progress notes are captured in either the clinical comments section of the observation charts or the in progress notes.
    Nursing Admissions are completed:

    • Neonates (Butterfly) – Neonatal Unit Nursing Admission/History, (MR 851/A)
    • Paediatric Intensive Care (Rosella) –PICU Management Plan, (MR 855/A)


    Emergency.
    The Emergency Department have department specific documentation tools, however progress notes should follow the structure as detailed above.

    Theatres.
    The Operating Suite uses ORMIS (Operating Room Management Information System) to record all surgical procedures
    http://www.rch.org.au/surgery/local_procedures/ORMIS_Nursing_Intra_Operative_Documentation/

    Banksia.
    The patient population in this unit requires assessment that is continuous throughout the shift and so commencement of shift assessment and plan of care are incorporated into progress notes.

    Nursing Admission - Day stay.
    May be used for patients staying less than 24hours in the areas of Day Medical Unit or Day of Surgery.

    Wallaby Ward.
    Commencement of shift assessments are completed verbally within two hours of the shift commencing by contacting families.

    • “How is your child?”
    • “Is there any change with your child since yesterday?”

    Verbal commencement of shift assessments along with ABCDF, risk, OH &S and medication assessments are documented on the Patient care plan (MR 856/A).

    All plans for care are documented on the Patient care plan and real-time progress notes should follow the structure as detailed above.

    Less than 24hr Admissions (Oximeters + Ambulatory Blood Pressure Monitoring)
    Commencement of shift assessment and real-time progress notes are documented.
    Note: do not require Nursing Admission Forms.

    CVC Care
    Commencement of shift assessment, Patient care plan and real-time progress notes are documented.
    Note: do not require Nursing Admission Forms.

    Companion Documents

     

    Evidence Table

    Complete evidence table document available at http://www.wch.org.au/nursing/governance

    References

    • Björvell, C., Thorell-Ekstrand, I., & Wredling, R. (2000). Development of an audit instrument for nursing care plans in the patient record. Quality In Health Care, 9(1), 6-13.
    • Blair, W., & Smith, B. (2012). Nursing documentation: Frameworks and barriers. Contemporary Nurse, 41(2), 160-168
    • Cheevakasemsook, A., Chapman, Y., Francis, K., & Davies, C. (2006). The study of nursing documentation complexities. International Journal of Nursing Practice, 12, 366-374.
    • Collins, S. A., Cato, K., Albers, D., Scott, K., Stetson, P. D., Bakken, S., & Vawdrey, D. K. (2013). Relationship between nursing documentation and patients’ mortality. American Journal of Critical Care, 22(4), 306-313.
    • De Marinis, M. G., Piredda, M., Pascarella, M. C., Vincenzi, B., Spiga, F., Tartaglini, D., Alvaro, R., & Matarese, M. (2010). ‘If it is not recorded, it has not been done!’? consistency between nursing records and observed nursing care in an Italian hospital. Journal of Clinical Nursing, 19, 1544-1552.
    • Jefferies, D., Johnson, M., & Griffiths, R. (2010). A meta‐study of the essentials of quality nursing documentation. International journal of nursing practice, 16(2), 112-124.
    • Johnson, M., Jefferies, D., & Langdon, R. (2010). The Nursing and Midwifery Content Audit Tool (NMCAT): a short nursing documentation audit tool. Journal of nursing management, 18(7), 832-845.
    • Kargul, G. J., Wright, S. M., Knight, A. M., McNichol, M. T., & Riggio, J. M. (2013). The hybrid progress note: Semiautomating daily progress notes to achieve high-quality documentation and improve provider efficiency. American Journal of Medical Quality, 28(1), 25-32.
    • Newell, R., & Burnard, P. (2006). Vital notes for nurses: research for evidence-based practice. Oxford; Malden, MA Blackwell.

    Document Control

    Complete document control document available at http://www.wch.org.au/nursing/governance

     

     Please remember to read the disclaimer

     

    The development of this nursing guideline was coordinated by Sophie Linton, CNC, Nursing Innovation and Kylie Moon, CNC, Nursing Innovation, and approved by the Nursing Clinical Effectiveness Committee. Updated November 2014.