1. Nurses’ Notes: Accurate Documentation
Lisa L Osborne RN, BSN
Rhonda Keen RN,BSN

2. Introduction
Giving complete and accurate information about your patients to the next shift helps protect your patients and colleagues.

3. Reporting Models
1. Body systems. Present your report based on the patients body systems.
2. Head-to-toe. Describe from "top down" what you need to tell the next shift.

4. Reporting Models
3. Reporting by exception. Focus solely on variances or patient problems. Cover nursing care provided, the patient's current condition, and the care he/she needs during the next shift.
4. Other nursing models. Consider other nursing models to organize your report, such as by the four modes: physiologic condition, self-concept, role function, and interdependence.

5. Methods For Documenting Nurses Notes
Narrative:
The nurse may be asked to chart in chronological order the events that occur including the gathering of information.
A sentence structure.
There may be a separate column for treatments, nursing observations, comments, etc.
Narrative charting is time consuming, so legibility is extremely important if the notes are to be understood by those reading them.

6. SOAP:
This is an acronym for Subjective data, Objective data, Assessment, and Plan.
Some facilities use the acronym SOAPIE in which Implementation (nursing actions or interventions) and Evaluation have been added.
And then, there is SOAPIER in which Revision is the last component. Following each letter of the respective acronym used, the nurse is required to chart information relevant to that particular term.

7. APIE:
This is a more recent method which requires the nurse to include Assessment, Plan, Implementation and Evaluation.
It is a method, which condenses client data into fewer statements by combining subjective and objective data into the Assessment section and combining nursing actions (what the nurse will do) with the expected outcomes of client care (what the client will get or experience) into the Plan component.

8. PIE:
This is an acronym for Problems, Intervention and Evaluation of nursing care.
The system consists of a 24-hour flow sheet combined with nursing progress notes.
The notes are usually written as client problem statements using an approved nursing diagnosis. Problems are labeled "P" and given a number, nursing interventions are labeled "I" and evaluations of the nursing action or intervention are labeled "E."

9. Flow Sheets:
These are often called "graphic records" and are used as a quick way to reflect or show the client's condition.
They are helpful records in documenting things such as vital signs, medications, intake and output, bowel movements, etc.
The time parameters for a flow sheet can range from minutes to months. For example: In an intensive care unit a blood pressure might be recorded every 5 minutes while in a clinic setting a weight may be recorded only once a month.

10. Focus Charting:
The term focus was coined to encourage nurses to view the client's status from a positive perspective rather than the negative focus in problem charting.
The system uses three (3) columns. Note the information that is usually required in the third column titled Progress Notes (called the DAR).

11. Charting By Exception (CBE):
This is a system of charting in which only significant findings or exceptions to standards or norms of care are recorded or charted. Flow sheets or charts are used in which check off marks are recorded.
Recording an asterisk (*) means that a standard or norm of care was not implemented. The asterisk (*) also means that a narrative nurses note has been charted to explain why the standard of care was not met or satisfied.

12. Nursing Process
Regardless of the system of documentation that is used, nurses universally use or refer to the Nursing Process as a guideline when they are charting. The Nursing Process contains the following four (4) phases of nursing care:
 1. Assessment: observing the client for signs and symptoms that may indicate actual or potential problems.
 2. Planning: developing a plan of care directed at preventing, minimizing or resolving identified client problems or issues.
 3. Implementation: practicing the plan of care that has been developed; includes specific actions that the nurse needs to take to activate that plan.
 4. Evaluation: determining whether the plan of care was effective in preventing, minimizing or resolving
identified problems.

13. Regardless of the approach you use, certain rules apply:
Organize your time so you're ready to give report when the oncoming shift arrives.
If you didn't receive complete information from the previous shift, search for pertinent details in the patient's medical record and include them in your report.
Review the data you've entered on your formal report sheet and take the sheet with you when you give report.

14. 4. Be brief and direct. You don't have much time to exchange information.
5. If you began a task that someone on the next shift needs to complete, point out what must be done and when. For example, if a patient received pain medication just before the end of your shift, mention that pain evaluation is due and indicate the time.

15. In the world of nursing and malpractice, the best way to avoid having to defend yourself in court is to chart factually and defensively. This involves knowing:
How to chart
What to chart
When to chart
Who should chart.

16. HOW to chart Rule #1: Stick to the facts.
Record only what you see, hear, smell, feel, measure and count, not what you infer or assume.
Don't chart your opinions; the chart is used as evidence in court
For example, if a patient pulled out his IV. line, but you didn't witness him doing so, write: Found pt., armboard, and bed linens covered with blood. IVline and venipuncture device were untaped and hanging free. If the patient says he pulled out his IV line, record that.

17. Rule #2: Avoid labeling.
Objectively describe the patient's behavior instead of subjectively labeling it.
Expressions such as exhibiting bizarre behavior mean different things to different people. Could you define these terms in court?

18. Rule #3: Be specific.
Your charting goal is to present the facts clearly and concisely.
Use only approved abbreviations and express your observations in quantifiable terms.
For example, writing output adequate isn't as helpful as writing output 1,200 ml.

19. Be specific
Pt appears to be in pain is vague compared with Pt requested pain medication after complaining of severe lower back pain radiating to his right leg.
Also avoid catchall phrases, such as Pt. comfortable. Instead, describe how you know this. For instance, is the patient resting, reading, or sleeping?

20. Rule #4 Use neutral language
Using inappropriate comments or language is unprofessional and can cause legal problems.
In one case, an elderly patient developed pressure ulcers, and his family complained that he wasn't getting adequate care. The patient later died, probably of natural causes. Because his relatives were dissatisfied with the patient's care, they sued. The insurance company questioned the abbreviation PBBB, which the physician had written in the chart under prognosis. After learning that this stood for "pine box by bedside," the jury awarded the family a significant sum.

21. Rule 5 Eliminate bias
Don't use language that suggests a negative attitude toward the patient, such as obstinate, drunk, obnoxious, bizarre, or abusive.
"This nurse called my client `rude, difficult, and uncooperative.' It's right here in her own handwriting! No wonder she didn't take good care of him.
Its better not to state the obvious, paint a picture instead

22. Rule #6 Keep record intact
Discarding pages, even for innocent reasons, raises doubt in a lawyer's mind.
Let's say that you spill coffee on a page, blurring several entries. Don't discard the original. Rewrite it and put both pages in the chart. Then cross-reference them by writing Recopied from page on the copy and Recopied on page on the original.

23. WHAT to chart Rule #1: Chart significant situations.
Learn to recognize legally dangerous situations as you give patient care. Assess each critical or out-of-the-ordinary situation and decide whether your actions might be significant in court. If they could be, chart them, as well as every other detail of the situation.

24. Rule #2 Chart complete assessment data.
The failure to perform and document a complete physical assessment is a key factor in many malpractice suits.
During your initial assessment, focus on the patient's chief complaint, then follow up on all other problems he mentions.
Be sure to chart everything you do and why.

25. Rule #3 Document discharge instructions.
Patient and family teaching usually is your responsibility. If a patient gets inadequate or incorrect instructions and an injury results, you could be held liable.

26. WHEN to chart
Rule #l: Document nursing care when you perform it or shortly afterward.
Never document ahead of time; your notes may be inaccurate and you'll leave out information about the patient's response to treatment.

27. WHO should chart
Rule #1: No matter how busy you are, never ask another nurse to complete your charting (and never complete another nurse's charting).
Doing so is a dangerous practice that your state's nurse practice act may specifically prohibit.
If the other nurse makes an error or misinterprets information, the patient can be harmed.
If the patient sues you for negligence, both you and your facility will be held accountable because delegated documentation doesn't meet nursing standards.

28. Examples of Nursing Notes

29. Nurses' notes to track the course of baby's visit to the ER
11:05 Resting quietly with eyes closed. Monitor shows ST (sinus tach). BP down to 69/53. Dr. XXX notified of patient status. Pulse oximetry down to 84%. Color dusky. Received order …such as placed infant on non-rebreather 100%;began fluid bolus
11:09 Monitor continues SVT rate 280s. Baby awake, eyes open, sucking on pacifier. Color dusky. ER Dr. notified of patient condition and order of Adenocard given STAT

30. 11:16 Monitor continues SVT rate 280s
11:16 Monitor continues SVT rate 280s. Baby lying very still with eyes open. Resp 48, shallow but regular. Unable to obtain BP reading at this time. Color remains slightly dusky.
11:23 Dr. ZZZ in to see patient. Adenocard 0.45 mg. IV given at 11:24. 11:25 monitor shows SVT to ST rate 140s.

31. Other Examples
93 year old Caucasian female admitted by wheelchair from hospital. Patient is not oriented and cannot speak coherently. Soon after admitting the patient, he began shouting a syllable over and over, despite one-on-one time by staff. Patient has history of CVA. Stroke protocol initiated

32. Continued……
Vital signs - temperature 98.4, pulse 84, respirations 18, blood pressure 108/82. Patient continues with oxygen at 3 liters per nasal cannula. Patient's respirations even, with open mouth breathing. Oral care given and large mucous secretions removed. Patient able to close mouth and breath through nares; circulation - less than 3 second capillary refill in all four extremities. Patient responded to tactile touch by opening eyes. Right eye remained open. Patient not able to respond to hand grip, lungs decreased in bases bilaterally.

33. Contiued
Patient has can fed self and responded to questions appropriately this week, but at other times has been unresponsive, unable to feed self, staring with flat affect or sitting with eyes closed, refusing medications or food by tightly clamping lips together. Physician notified awaiting further orders will continue to closely monitor R.Keen, RN

34. MORE
Patient rested quietly thorughout shift. Respirations slow, deep and regular. Observation every 15 minute nursing checks. L. Wilson, RN 
Behavior - patient has been asleep during shift. Patient has been unresponsive. Patient has had to be put on oxygen and suctioned times one. Patient has decreased health wise during shift. Intervention - offer patient meals, groups, one-on-one. Response - patient ate 10% of breakfast and none of lunch. Patient didn't attend group because patient was unresponsive and sleeping. Patient would not arouse during shift. Plan - follow care plan. Check and record patient health status. T. Sprague, RN
What is wrong with this?

35. What is wrong?
Behavior - patient up in chair, nonresponsive, nonverbal, is not eating, sleeping most of morning. Intervention - nurse gave medications as ordered, see Medication Admin log;provided quiet environment. Response - non-responsive; patient is alert and oriented x 3. Plan - provide a safe environment according to treatment plan. Lee, LPN.

36. PROBLEM
Problem: altered thought process Behavior - patient was somnolent most of the shift. Respirations slow and regular. Rate Family visited and attended a lengthy teaching session with this LPN regarding patient's current medications and expected course of treatment/ care during this hospital stay. Family repeated the request that patient be made comfortable and requests that she be a "Do Not Resuscitate". Patient ate dinner with feeding by staff. Roused at 2000 and began to moan and cry. Intervention - bedtime medications given with calming effect after tearful episode. Response - Family voiced understanding of purpose of all medications. Understanding of the purpose/goal of comfort measures was also articulated by family. Plan - continue current treatment. Administer medication. Provide safe environment. Reinforce family education. L.Wilson, LPN 

37. A Nursing Note be Evaluated
Patient has become increasingly agitated since shift change at 1500; trying to get up without assist; yelling in worried, angry voice "will you let me, why won't you let me!?" and other nonsense sentence fragments, or repeating phrases she just heard the staff utter. Patient medicated with Ativan 2 mg by mouth. L. Long, LPN.

38. Progress Notes
Patient still agitated - yelling, crying, trying to get out of bed. L. Long, RN.
Behavior - patient disoriented, demented, and agitated all shift. After getting eye drops administered by RN, patient tried to put popcorn in her eye, saying "should I put it in now?" Intervention - offered movie, meal, one-on-one, medications as ordered, assist with all activities of living. Response - patient couldn't focus on movie or any activity for long. Would try to get up, or reach for invisible objects, or play with objects within reach. Patient fed self. L. Long, RN
Patient was continent this shift. Plan - therapeutic safe environment, assist with activities of daily living, constant supervision. L. Long, RN

39. Activity
Seizure activity - patient checked frequently throughout the night; resting quietly with eyes open - respirations even and unlabored. Would track with eyes when spoken to. At 0540 patient began to grunt and gradually patient's right side began to jerk - right leg, arm, face, etc. Vital signs - blood pressure 160/100, pulse 92, temperature House supervisor notified. M.D. (Dr. Dienhart notified) and IV of D5 started as ordered, Ativan 3 mg IV given and no improvement noted. Dr. Dienhart called. Additional 1 mg Ativan given and patient calmed - no jerking - respirations free and easy. IV changed to normal saline and Dilantin, 1 gm infusing over 40 minutes. Blood pressure 104/60, respirations 20. Dr. Dienhart in to see patient. Oxygen at 2 liters per nasal cannula. To X-ray department by cart for CT scan. Oxygen saturation 90% on 2 liters. EKG done. IV changed to D5 2 NS at 70cc per hour. Patient returned from X-ray. IV discontinued. Blood pressure 70/40. Periods of apnea. Dr. Weitzel notified. T. Scholl, RN.

40. MORE
Patient's medical status has rapidly and profoundly deteriorated this week. She has experienced a seizure and multiple episodes of vomiting coffee grounds material. She is no longer verbally responsive. The care plan has been altered to reflect the need to support patient and family through a positive death and dying process.  Patient is currently receiving morphine sulfate intramuscularly every 3 hours for comfort. L. Wilson, RN.

41. Even more
Behavior - patient unresponsive to verbal stimuli, patient weak. Heart rate irregular, respirations even, nonlabored at this time. Patient diaper changed once, with urine output. Patient not able to orally intake. (B.Hardy, RN) Dr. Weitzel notified of patient condition. Doctor stated he would be arriving soon. B. Hardy, RN Patient with approximately 100 cc emesis - dark brown coffee grounds coming from nares and mouth. (continued) B. Hardy, RN.

42. Continued…
Patient cleansed - no response. Heart rate tachycardic and irregular, respirations even nonlabored, shallow. B. Hardy, RN.
Patient family in to see patient. Aware of physical status change. Family stated they want Do Not Resuscitate status maintained and comfort measures given. B. Hardy, RN Dr. Weitzel ordered morphine sulfate IM to be given every 4 hours round the clock. Patient not orally intaking. Oral care given and position changed.  B. Hardy, RN.

43. Continued
Lung sounds decreased in bases bilaterally. D. Kley, RN Patient respirations irregular, Cheyne-Stoking. Opens eyes to name. Resting quietly. D. Kley, RN Patient continues to rest quietly in bed. Respirations even. Responds with eye opening to name. Lethargic, with drawn appearance. Has taken no oral intake this shift. Turned every 2 hours, frequent oral care done. D. Kley, RN Called son, gave status report on patient's condition. Son (Merlin) stressed that Aonly wished to keep her comfortable. D. Kley, RN Behavior - patient has been resting quietly this shift. Respirations slightly labored at times. Cheyne-Stoking at times. Opens eyes to name. Does not respond verbally. Took no oral intake. Intervention - medications held this shift as do not feel patient alert enough to swallow. Patient turned every 2 hours with frequent oral care given. Monitored frequently and closely. Response - patient has appeared to be resting comfortably this shift, no restlessness noted. No skin breakdown.  D. Kley, RN

44. Further more
Opens eyes to name. Does not respond verbally. No oral intake this shift. Plan - continue to administer intramuscular morphine as ordered. Turn every 2 hours. Provide frequent oral care. Keep doctor/family aware of patient's status. Monitor for skin breakdown. Provide comfort measures. D. Kley, RN.

45. Patient resting with eyes closed, no twitching, deep respirations noted. B. Hardy, RN.
Patient with decreased heart rate and deep respirations 10 and with moments of deep sighs and irregularity. No twitching movements. B. Hardy, RN.
Patient without vital signs present. Listened times 5 minutes for heart rate and respiration. None noted. Supervisor, doctor, and social worker notified. B. Hardy, RN  

46. Social worker spoke with son of deceased patient. Dr
Social worker spoke with son of deceased patient. Dr. Weitzel gave order to release body to mortuary. Family declined to view body at hospital, requested mortuary pick up as soon as possible. Mortuary notified. Patient cleansed and belonging bagged for family pickup. No valuables in patient possession. B. Hardy, RN Mortuary picked up patient and signed for pickup. B. Hardy, RN

47. Foley care Check orders please. Document education/permission.
16F10ml sterile water Foley catheter inserted using sterile technique lidocaine jelly as ordered upon insertion patient tolerated with minimal discomfort denies pain after insertion. 500ml straw colored urine immediately returned ;place Foley closed bag system to gravity drain; patient instruction given on the foley and patient verbally demonstrated understanding. Bed low positon, call light in reach, patient watching television and denies further needs as present. RKeen, LPN

48. IV insertion
20 G angiocath inserted using aseptic technique left forearm x1 attempted patient tolerated the procedure well stated “it only hurt a little”. Secured with tegaderm and tape flushed with 10ml normal saline site free from signs or symptoms or infiltration or infection. Educated the patient to call out if pain, swelling occurs patient verbalized understanding ……..

49. Advice from the Experts…
Don’t chart staffing problems
Don’t record staff conflicts
Don’t mention incident report
Don’t use words associated with errors ..ie somehow, accidently confusing
Don’t name a second patient write roommate
Don’t chart casual converstations

50. MORE Chart the informed consent Advance directives Living will POA
Patient’s refusing treatment Who can do that?
Restraints – other methods exhausted first

51. MORE…………………gosh Patient’s request to see the chart AMA
Anything and everything that shows prudent care given, educated, reassess, taught. Or done

52. Thoracic drainage Date and time Type of system used Amount of suction
Presence or absence of bubbling
Amount and type of drainage, respiratory status, how frequently you assess the bandage amount of drainage and condtonion, bubbling and resp status

53. Cardiac monitoring
Date, time monitoring began, leads used lead II or I, Initial rhythm; any change in condition, ie chest pain; abnormal rhythm and what was done; etc……….Shift strip and chart if an abnormal was noted and what was done patient has tachycardia while using the toilet for example

54. NGT insertion Type, size date and time Insertion right left oral
Type and amount of suction
Amount, color, consistency and odor of draininage
How it was tolerated
Signs of complications
Record shift assessment

55. IF that is not enough TOO bad LOL……………..

56. References
"Charting defensively.“ Nursing. May FindArticles.com. 06 Oct
Methods For Documenting Nurses Notes. Retrieved Oct. 6th , 2006, from

57. References
Get an A+ on end-of-shift report. Nursing,  Jun 2004  by McLaughlin, Evelyn,  Antonio, Lourdes,  Bryant, Annette. Retrieved Oct. 6th , 2006, from