Documenting patient care can be a daunting task.
- What did I do today?
- Do I really need to write all of this down?
- Is what I’m writing making any sense to someone else reading it?
- Have I kept any personal judgements out of the notes? (e.g. patient is friendly)
- Did I use ambiguous terms like ‘ok’, ‘good/bad’, ‘high/low’ without giving more specific information? (e.g. ‘pulse low’ versus ‘pulse low (39)’)
- What are the things that other members of the Multidisciplinary Team (MDT) need to know about the care I gave my patient today? (e.g. how much is too much information?)
Document as you go along or in one large paragraph at the end of the shift
It is considered good practice to write about care as it happens so that you are less likely to forget or incorrectly document any care that has been provided. In practice, however, you may find it difficult to set aside time to write in bits and pieces throughout the day. Most nurses tend to record important clinical decisions, test results, scores etc. on their handover sheet as they go and then document it all in one sitting later on in the shift. You will gradually find what you are comfortable with and what works for you on your ward. Just remember that documenting care accurately is very important. You will often hear staff say that documentation is your safeguard against lawsuits or the NMC questioning your practice. I prefer to consider the patient’s situation first and say that accurate documentation benefits your patient immensely by keeping them safe. If the rest of the team is up-to-date with what care the patient has already received, what stage they are at with mobility, continence, wounds etc. then other staff will be better equipped to plan their own further interventions.
Different types of documentation systems
You’ll see lots of different systems for documenting patient care. Every ward/district/trust does it slightly differently.
Among the possibilities you will see are:
- preprinted care plans that just require a signature and may have a free text set of blank lines on the back to note anything out of the ordinary,
- reams of blank line sheets just on their own – usually called ‘continuation sheets‘ – where all the care is documented in paragraph style,
- separate styles of continuation sheets for nurses and medical staff where doctors, physiotherapists (physios), occupational therapists (OTs), etc. will document their patient visits on one type of sheet with blank lines and nurses will use another slightly different type with blank lines,
- places where all staff write on the same sheet with blank lines and nurse, doctor and OT notes will all be mixed up together with or without preprinted care plans.
Writing in preprinted care plans can seem easier as there is a defined structure that prompts you to provide the pertinent information. It can also be frustrating when you have something to add that doesn’t quite fit in any of the care plans as they are often rather specific. Some nurses will tell you that they ignore the small areas for free text on the preprinted care plans and simply rewrite everything in a main continuation sheet of nursing notes. Again, you will find what works best for you and your workplace. There are arguments for and against any method as well as arguments for and against an NHS wide standardisation and a ward specific way of documenting. This is ongoing and you’re likely to see as much change in your job once qualified as you have done during your training!
Keeping it accurate, concise and comprehensive but relevant
Easier said than done, right? You know what you have accomplished on the shift, but to condense everything down into a smallish paragraph can be tricky. It is definitely a good idea to start getting a pattern to what you write which will help you avoid missing out any care given. I have seen people who write chronologically, some who write according to body systems (e.g. anything to do with respiratory first, then anything to do with cardiovascular, then renal etc.) and those who have their own set pattern.
This is an example of how you might consider setting out your notes. It would be written in paragraph form, not bullet points as gaps should not be left on lines to prevent additions to your writing after you have signed it. You will find this is something nurses stick to but medical staff do not.
- Written retrospectively
- Patient care taken over at 07:30.
- Initial observations completed, EWS = 1 due to low systolic (93/51). Monitored over next hour and currently EWS=0.
- Patient reports no pain/nausea.
- No shortness of breath. SpO2 and respiratory rate within range. Patient on nasal spec (2L O2).
- Patient required some assistance x1 with wash this morning.
- All pressure areas intact, SKIN Bundle completed.
- Passing urine but bowels not opened as of 13:30.
- Diet and fluids taken.
- Anti-hypertensives and diuretic withheld due to low systolic, all other medications administered as prescribed. Patient encouraged to drink fluids. Medical staff informed.
- Patient mobilising independently with frame – advised to request support if required.
- TED stocking (large) removed and reapplied after 30 minute rest.
- Surgical wound (right knee) dressing dry and intact. No signs of inflammation/infection.
- Recent test results: Hb 132, Urine dip = NAD, MRSA negative
- Section 2 sent
- All care explained, patient fully capable of expressing needs.
- Water and call button in reach.
- Patient reports comfortable, no concerns at present.
The majority of this is pertinent to most patients. Some will be shorter if, for example, their EWS=0 you would just put ‘Initial observations completed, EWS=0.’ Or if they were on room air instead of nasal cannulae you could say ‘No shortness of breath. SpO2 and respiratory rate within range on room air.’ It is difficult to avoid repeating documentation, for example, I have not included VIP scores for a cannula as this more than likely will have its own separate sheet. Feel free to include it yourself. You will also no doubt think of something else I could have included and this is the nature of documentation. I guarantee you that as soon as you write the final line and sign your name you’ll remember something else to include and end up adding one more line at the end and signing all over again.
What is important?
Well everything and nothing really. Different healthcare professionals will tell you that they only want to hear about x, y, and z when others want a, b, and c. The best you can do is present the information in an organised fashion that clearly and concisely states the contact you have had with your patient. The information should also help staff to notice developing patterns. For example, if a patient has not opened their bowels for a few days and you notice this reading through the last entry, you may wish to discuss this with the medical team to see if an appropriate laxative can be prescribed. Or if a patient continually reports severe pain first thing in the morning, understanding why this is the case and discussing possible changes to their available breakthrough analgesia would benefit the patient greatly.
Remember this is a learning process and no one size fits all. Keep the safety and quality of your patient’s care at the forefront of your mind at all times and you will be fine.