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Nursing documentation tips and challenges


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Book excerpt

Nursing documentation tips and challenges 

Editor’s note: The following is an excerpt from the newly released Joint Commission Survey Coordinator’s Handbook, 12th Edition, by Laure Dudley, RN, MS, CSHA. For more information about the book or to order a copy, visit www.hcmarketplace.com/prod-9051.

When it comes to nursing documentation, a few areas tend to trip up organizations, requiring them to refocus their efforts. Let’s examine these areas.

It is required that an initial nursing assessment be completed within 24 hours of a patient’s admission, as stated in PC.01.02.03, element of performance (EP) 6. The hospital gets to define the information to be collected. In addition, a functional and nutritional screen must be conducted if indicated within 24 hours, but the standards don’t require that nursing conduct these screens. 

Many times, consultants see organizations piling on additional requirements, making it very difficult for the floor staff to execute the existing protocols. For example, one organization had in its policy start times for when an initial nursing assessment must be initiated. 

Different times were noted for the various areas in the hospital, such as the emergency department, the ICU, rehabilitation, maternity, and the medical-surgical units. 

When staff members were asked about this requirement, they were unable to articulate their particular unit’s assessment start times. Not only was the requirement complex for staff members to remember, but in some cases it was impossible for them to execute. 

An “immediate” initial assessment in the emergency department meant triage could never be backed up. The 10-minute requirement in the ICU meant there could never be a patient care issue that would interfere with starting the assessment. 

When brought to leadership’s attention, the implication of having such a policy on the operational aspects of patient care was realized. Needless to say, the organization plans to revise the policy.  

The standards require that a hospital have written guidelines with time frames included, and that initial patient assessments are conducted within this period. 

There is no requirement for any more stringent criteria to be included in your policy, such as starting the assessment, grading each aspect of the assessment with a numerical score, or other add-on processes that alter the complexity and don’t add value to the delivery of care. 

The same goes for the reassessment requirements as stated in PC.01.02.05—that qualified staff is obligated to assess and reassess patients. This leads us right into the crux of the care planning process.

Care planning

RNs are required to determine patient care needs based on the initial assessment. Many organizations are using some type of a fold-out shift assessment and care planning form to simplify staff members’ many documentation needs. Some organizations have instituted care paths that trigger individual care plans for each symptom or condition. 

These forms are then printed and added to the chart based on a nurse’s identification of a patient’s clinical problem, such as for pneumonia or unsteady gait. If a patient is admitted with multiple comorbid conditions, this can result in 10 additional forms and documents for nurses to complete each shift. This adversely affects staff efficiency and causes a loss of focus on important issues, such as the primary reason for admission. 

The overall plan of care should include goals that are focused on the identified needs of the patient. Think about your current process and the complexities involved for staff members to maintain all the requirements.

Tips for success: Organizations have successfully integrated the care planning aspect into the patient assessment process. This is a natural fit for the patient care delivery process. 

Some organizations have combined the assessment, care plan, and shift documentation into a single form. This has streamlined the staff’s focus while allowing the staff to deliver patient care services and not just the tasks assigned, such as remembering all the places to access patient information in the medical record. It also supports nursing in planning the patient’s care each shift.

Patient education

It’s pretty common to see “canned” or non-patient-specific education categories in the record, such as orientation to the room and other generic information checked off on a patient’s care plan related to education. Sometimes this is all you will see. Many organizations struggle to convert the information from the nursing assessment and plan of care to the education documentation section of the medical record. Since education is ongoing, doesn’t it make sense to incorporate it into a single interdisciplinary plan of care? Standard PC.02.03.01, EP 4 requires that education and training be based on the patient’s assessed needs. So, simply work the process into what you are already doing.

Here’s a list of a few of the findings related to this education requirement that will shed some light on what has been observed in patient records:

  • There is lack of patient education related to the isolation precautions implemented.
  • There is no notation of skin issues being addressed and the patient has a wound.
  • The patient has been in the hospital for 10 days and there has been no education since the day of admission. The patient has postoperative complications.
  • Despite a dietitian following the patient for weaning from total parenteral nutrition or peripheral parenteral nutrition, there is no evidence of patient education related to oral intake goals. 
  • There is lack of documentation of patient education of any kind in the record. 

The accompanying sample tool (see pp. 11–12) is a conceptual model form that combines assessment, care planning, education, and shift documentation into a single document. Many organizations have found that this results in more streamlined nursing documentation and that it focuses the nurse on care planning and shift priorities. Consider creating a simple document using the sample form included on the following pages as a guideline.

Other organizations have been very successful in using a continuous daily form that includes a place for each shift to update and document issues that arose on previous shifts. At a glance, staff members have immediate access to the status of these issues. This goes back to the old days when the Kardex ™ system was used to hold all relevant information on one piece of paper in a single location.

The bottom line is that if you can develop a system that encompasses the standard practice of delivering patient care, you will have a much greater chance of success.