5 Documentation of Health Assessment Findings
Learning Objectives
At the end of this chapter, the learner will:
1) document assessment findings using best practice standards
2) recognize variations in the documentation of assessment findings ( paper. electronic)
3) evaluate the legal implications of accurate and concise documentation in nursing practice.
I. Overview of Documentation of Assessment Findings
In the article Nursing record systems: effects on nursing practice and healthcare outcomes by Urquhart C, Currell R, Grant MJ, Hardiker NR nurses document to record the care that was planned, any deviations, and the actual care given to each patient by the registered nurse (RN) or any caregivers working with the RN to provide patient care. The article further states that documentation should demonstrate the legality of the care given and should be professionally completed. Legally only actions or care documented are seen as being completed. This sentiment is reflected by the nurse’s mantra of “If it was not documented, it was not done.” It is important that these rules apply to written documentation in the physical chart and electronic charting (EHR). Other aspects of documentation include the importance of documenting in a timely manner, avoiding using abbreviations, and writing the note in grammar-appropriate standard English. Remember, if the note goes to court it is important that the jury can read it grammatically and legibly.
Documentation is used for:
- creating plans of care.
- communicate findings
- ensuring continuity of care across shifts.
- proof of education given
- monitoring quality assurance.
- obtaining reimbursement by insurance, Medicare, and Medicaid.
- research and research-based interventions
- Discharge concerns/readiness-homecare needs
- legal concerns.
The primary care provider (MD, NP, PA), consulting physicians, social worker, Physical therapist, occupational therapist, nutritionist, and possibly the clinical pharmacist all use the progress note section to document. Nurses use the “Nurse’s Notes” or the progress note section to communicate therefore, it is important that the nurse read the physical or electronic progress note to determine the patient’s course of care and possible discharge dates.
Seven criteria for nursing documentation were presented in 2010 by Jefferies, Johnson, and Griffiths (2010:119) in the paper: “A meta-study of the essentials of quality nursing documentation.” The seven criteria for professional and legal documentation include Patient-centered, contain the nursing care given, reflect the nurses’ clinical judgment, is presented in a logical order, written in real-time, document variance in the patient’s care, and fulfill the legal requirements. The nurse needs to document significant events and information in any patient’s ongoing care from assessment, planning, intervention, and evaluation. Documentation facilitates safety and quality care in so many ways, one of which is the continuity of car