Right Chart: Check that you have the correct chart before writing.
Penmanship: All your documentation is to be legible so anyone can read it. If you have poor penmanship, begin to print. Your printing will make it easier to read your notes. Now that your nursing notes are legible, let's talk about the basics. Use permanent black ink pen. Other colors do not copy well.
Date and Time: Date and time every entry. The date should include the year; the time should indicate am or pm or be in military time. Don't chart in blocks of time such as 0700 to 1500. This makes it hard to determine when specific events occurred.
Client's history (including unhealthy conditions or risky heath habits such as scalp lice, smoking, failure to take prescribed medication, specific non-compliance issues and events, etc.) A client's history is usually reflective of trends and may offer valuable hints about what to expect in the future.
Subjective Information: It is important that you chart any subjective information. Document what you hear, what the client says, what the caregivers say, comments to you about how they feel, feelings of anxiety or depression, etc. Use direct quotes and place quotation marks around the quote. Chart a client's refusal to allow a treatment or take a medication. Be sure to report this to your immediate supervisor and the client's physician and document your calls.
Objective Information: Chart your observations, what do you see, vital signs, hard data such as any and all assessment information. It is especially important to document changes in health status such as the emergence of a productive cough, difficulty in breathing or changes in vital signs from their baseline. Did you address: mental status, functional status, mobility, cognitive ability, speech? Oftentimes when you are in the home every day you forget that the people reading your notes do not know the client so you need to show them on paper.
Interventions: Document any actions that you did in response to any of your observations and the client's response to your actions. These responses to your interventions are commonly called client outcomes. Chart the time you gave a medication, the route you gave it and the client's response. If a medication is a PRN, chart the reason it was given and the client's response to the medication (did it give the desired effect). Chart precautions, preventive measures used as well as any safety measures enacted, such as bed rails.
Client outcomes: Chart the client's response to your interventions, including those that are deviations from what you expected. For example: if a client is in pain, observe and document how that pain is experienced both objectively (what you see) and subjectively (what you hear). Record where the pain is and the level of intensity or severity (use a pain scale to do that). Record the medication and the backrub you give to relieve the pain and whether or not those actions were effective, i.e., did the pain persist, recur, or go away?
Document the client, family member or significant other's actual response (verbal or non-verbal) to any aspect of care provided even if you were not the one providing it. Doing so indicates that you have evaluated the results of care. It is perfectly acceptable to chart the client's verbal responses in the record as long as you use quotation (“) marks. Non-verbal responses should be described in as much detail as possible.
Make sure your documentation reflects the nursing process and your professional capabilities. Chart completely, concisely and accurately (“Tell it like it is.”). Write clear sentences that get right to the point. Use simple, precise words. Don't be afraid to use the word “I.”
Be sure to record your full name, credentials and job title in the required section on documentation forms. Some forms will ask you to record your initials as well. Your signature must be in cursive writing so a word of final caution: do take the time to sign your name legibly.
Client Education and Instruction: Other information that needs to be recorded in the medical record includes any education or instructions you give to the client, his family or significant other. Anytime there is a new medication or treatment the client, family member and other personnel must be educated and informed. Documentation of these actions is required. Include the fact that you informed the client/caregiver of the new order; chart the education of dosage, actions, side effects and schedule; chart that you made changes on the medication administration record or task sheets (if applicable); chart how you were able to communicate the new orders to other nursing personnel responsible for the client's care, document your communications regarding the new orders to the office.
Check Off Sheets: In some instances a pre-printed, standardized check off form may be used where all you have to do is check off or initial what you have done. The only time you may have to write any notes is when something is specific or unique to this particular client, something that can't be included on a standardized check off form. Remember: if you do not check off items, it means that legally the care was not done.
Phone Calls: We don't often think about phone calls, but they can contain certain information for which we have obligations such as advice that we may give to a client or a phone order that we may take from a doctor. To protect yourself in these kinds of phone conversations, a detailed summary of your conversations is charted in the client record.