Guidelines for Documentation
Accurate documentation and reporting are vital to proper client care. Reporting is oral communication between care providers that follows a structured format and typically occurs at the start and end of every shift or whenever there is a significant change in the resident. Documentation is a legal record of patient care completed in a paper chart or electronic health record (EHR). It is also referred to as charting. Checklists and flowcharts completed in the resident’s room may also become part of the paper chart. Documentation is used in a court of law to prove patient care was completed if a lawsuit is filed, with the rule of thumb being, “If it wasn’t documented, it wasn’t done.” Documentation is also reviewed by other health care team members to provide holistic care.
Accurate documentation should follow these guidelines:
- The client’s chart is confidential and should only be shared with those directly involved in care. If using paper, cover information with a blank sheet. When using technology, be sure screens are visible only to you and log out after each use. Never share security measures like passwords or PIN with anyone else.
- Document as soon as any care is completed.
- Include date, time, and signature per facility policy.
- Use facts, not opinions. An opinion is, “The resident doesn’t like their food.” Instead, a fact should be charted, such as, “The resident refused their meal and stated they were not hungry.”
- Use measuring tools, such as a graduated cylinder or a tape measure, whenever possible to provide accurate data. If you do have to estimate, provide a comparison such as, “Drainage noted on the bandage was the size of a quarter.”
- If you chart on paper, always use a black pen. If you make a mistake, draw only one line through the entry, write the word “mistaken entry,” and add your initials. Do not use correction fluid or completely black out the entry.
Long-term care facilities are required to complete additional documentation called a Minimum Data Set (MDS). The MDS is a standardized assessment tool for all residents of long-term care facilities certified to receive reimbursement by Medicare or Medicaid. The MDS is completed by a registered nurse who reviews documentation by nursing assistants to complete some parts of the MDS. Accurate documentation is vital so that facilities are appropriately reimbursed for the services provided to clients.
The MDS nurse will review the nursing assistant’s documentation pertaining to a resident’s sensory abilities, specifically their communication skills, hearing, and vision. For this reason, documentation must be accurate and thorough regarding assistive devices, the amount of assistance required, and skin observations. For example, devices for communication, such as whiteboards, photo books, charts, hearing aids, or glasses, must be appropriately documented, as well as the amount of assistance required for dressing, bathing, eating, toileting, repositioning in bed, transferring, and ambulating. Skin observations made during cares should also be thoroughly documented so they can be included in MDS reporting.
Guidelines for Reporting
Reporting client information to other nursing assistants or to a nurse for follow-up is an important part of meeting client needs and providing competent care. When providing an oral report, be mindful of confidentiality and where the report is given so no one overhears private information. Appropriate places for reporting include a closed room, a nurse’s station away from resident rooms and common areas, or in a private resident’s room with the door closed.
Throughout this textbook, specific information that should be documented and reported will be noted. Generally, a nursing assistant should report any physical changes in a client that seem unusual or behavior that is out of the ordinary for that person. Examples that require immediate notification to the nurse may include the following:
- Strong odors from urine, oral care, or wounds
- Reddened, warm, or open skin areas
- Difficulty breathing or chest pain
Objective information includes information about a client that can be observed through the four senses of sight, touch, hearing, or smell. This information is referred to as signs. Objective information can be verified by another individual and often includes measuring tools such as a scale, thermometer, specimen cup, or graduated cylinder. An example of objective information is the client’s temperature was 98.6 degrees Fahrenheit.
Subjective information is information reported to you by clients or their family members. This information is referred to as symptoms. It is documented by using the exact wording reported with quotation marks. An example of subjective information is the resident stating, “I have a headache.”
Military time is used to record the time care is provided and any other pertinent information for the resident. It avoids confusion between daytime and nighttime hours because it does not require a.m. or p.m. Each hour of the day has its own number from 1 to 24 and no colons are used. Beginning at 1:00 p.m., simply add 12 to the hour. For example, 1:46 p.m. is written as 1346. For morning hours up to 9:59 p.m., add a zero in front of the hour. For example, 9:24 a.m. is written as 0924. Midnight is documented as either 2400 or 0000.
When reporting in military time, morning hours are pronounced beginning with “zero” or “O.” For example, 7:00 a.m. is pronounced “zero seven hundred” or “oh seven hundred.” The time of 2:43 p.m. is pronounced “fourteen forty-three.” See Figure 1.6 below for conversion from civilian to military time.
Oral communication between care providers that follows a structured format and typically occurs at the start and end of every shift.
A legal record of patient care completed in a paper chart or electronic health record (EHR).
A standardized assessment tool for all residents of long-term care facilities certified to receive reimbursement by Medicare or Medicaid.
Anything that can be observed through sight, touch, hearing, or smell.
Objective information obtained through the senses of sight, hearing, smell, or touch
Anything a client says or does that cannot be measured. An example of subjective information is the resident stating, “I have a headache.”
Subjective information reported by clients or their family members. Symptoms are documented by using quotes around the exact words expressed by the client or their family member. For example, the client reported, “I have a headache.”
A standard for recording time that avoids confusion between daytime and nighttime hours because each hour of the day is represented by a number ranging from 00:00 to 24:59.