Medical Record Documentation
At the end of this class you will be able to:
Medical records are legal records that must be done in a very careful legal way. They must also be used in a legal way. They:
Documentation in these records must be:
Hospitals and nursing homes use many kinds of forms and ways to document the care that patients get. Daily care and hygiene in some places is written on a flow sheet form. In other places this care is written in a progress note. In still other hospitals and nursing homes, this daily care is put into a computer. Many hospitals and nursing homes are now using a computer. They do not use any paper forms any more.
You must follow the rules that are in place at your own hospital or nursing home. Ask the nurse if you are not sure of where you should write about your patient or resident,.
Documentation must be complete. You must record everything that you do and everything that you observe.
All care and all treatments must be recorded. You must also record all your observations of the patient. You must record all of the things that you see, feel, and hear, especially if they are not normal and/or not normal for the patient that you are taking care of. You have to document EVERYTHING. If it is NOT documented, it was NOT done. So, if you have done it, take the time to document it.
If you gave your patient a complete bed bath and the patient told you that they have a headache, you must record the fact that you have given the person their bath and that they have told you that they have a headache. You should also tell the nurse about the head pain as soon as possible. This observation, and all other observations that are not considered normal, must be reported to the nurse right away. It should also be written in the person’s medical record as soon as possible.
Some of the care that nursing assistants must document are:
Some of the observations that nursing assistants must document are:
All of your documentation in the patient or resident chart must be correct. If a person’s temperature was 101.4 at 2:30 pm, the reading and the time that it was taken must be written in the correct way. You should not write that it was taken at 2 pm if it was taken at 2:30 pm. And, you should not write that it was 101 degrees when it was 101.4.
You must also write only those things that you actually do, see, hear or feel.
You should not write, “The resident is lazy today.” This may not be true. You did not see “lazy”. You thought that the person may be lazy, but you did not see or hear lazy. It may not mean that a patient is “lazy” when you see them sleep most of the day. They could be very ill. Or, it may be that they did not sleep at all the night before because the other patient in their room was noisy all night.
Instead, you should write, “The patient slept from 8 am until 12 noon and was only awake when vital signs were done at 10 am” or, if the person says they are feeling lazy, you should write and report that the patient said, “I am feeling very lazy today”.
Documentation must also be done on time. It must be done in a timely manner. It must be done as soon as possible because documentation used to communicate about the patient or resident. It must be ready to see and ready to use for decisions. You should NOT wait until the end of the shift to do it. It is a very important part of care. Take the time to document and report as often as needed.
Could this injury have been prevented?
The injury to the other person may have been prevented if the nursing assistant had reported and recorded this behavior right after it happened. The resident could have been:
What should the nursing assistant have done differently?
All facts and findings that are NOT normal must be reported immediately and then documented in the person’s medical record. It should also be reported orally to all those that care for the person.
This nursing assistant should have reported the anger to the nurse as soon as it happened. The nursing assistant should also have written this behavior in the person’s medical record. This communication is very important. Documentation and reporting should be done as soon as it happened. You should never wait until the end of the shift to write or report things that are not normal.
Medical records are legal documents. They must be used according to the law and the policies of your own hospital or nursing home. They must also be kept according to the law and the policies of your own hospital or nursing home.
Some things that are you should do in order to make sure that you treat these records as legal documents are:
Documentation should also be professional. Handwriting should be neat and easy to read. Spelling should be correct. Look up the spelling of a word if you do not know how to spell it.
Also, be professional and careful with what you write. These records are not the place to air your own feelings about the patient and their care. For example, you should never write that “the nurse has not seen the patient all morning” or something like, “As usual, the doctor has not come to see the patient after he was called.” These statements are not at all professional.
Medical Records, whether or not they are on the computer and on paper, hold very important information about the patient and their condition. These records must be complete, accurate, timely, legal and professional. Well done medical records help the members of the healthcare team to communicate and coordinate care.
Berman, Audrey, Shirlee Snyder, Barbara Kozier and Glenora Erb. (2010). Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice. 8th Edition. Pearson Prentice Hall.
Nettina, Sandra M. (2009). The Lippincott Manual of Nursing Practice. 7th Ed. Lippincott, Williams and Wilkins.
Copyright © 2010 Alene Burke
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