9.4 : Guidelines for Nursing Documentation I

Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:

Factual:

The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.

• A factual record includes descriptive and objective information from direct observations and measurements, covering what a nurse sees, hears, feels, and smells.
• It is encouraged to use specific and measurable details, avoiding the use of vague terms like "appears," "seems," or "apparently" for clarity and precision.
• Objective documentation also includes observations of a patient's behaviors, highlighting the need to avoid subjective interpretations. Instead of simply stating that a patient "seems anxious," the passage provides concrete signs of anxiety, such as an elevated pulse rate, labored respiratory rate, and increased restlessness.
• Subjective data is limited to the patient's statements, which should be documented verbatim within quotation marks whenever possible.
• Supplementing subjective data with objective information is recommended to provide a more comprehensive understanding of the patient's condition and enhance the descriptive quality of the chart.

Accurate:

• The crucial aspect of accuracy in healthcare documentation is essential for precise measurements. Exact measurements contribute to accuracy, such as specifying "Intake, 360 mL of water" instead of a more general statement like "Patient drank an adequate amount of fluid."
• Accurate documentation involves providing detailed descriptions, such as noting the exact measurements of an abdominal wound in centimeters and detailing its condition with descriptors versus ambiguity.
• Clear documentation is succinct and avoids unnecessary words and irrelevant details. It also facilitates effective communication among healthcare professionals. Superfluous patient information, such as “the patient watching television,” is only necessary if it impacts their status and care plan.
• Patient safety is addressed by avoiding the careless use of abbreviations within the medical record. It is recommended to spell out abbreviations when confusion arises to minimize errors and use only approved ones.
• Accurate spelling in healthcare documentation is emphasized to prevent misinterpretation, particularly for terms with potential confusion.
• Precise transcription of medications by providers is critical to avoid errors, especially with drugs that sound similar or are similar in spelling. Additional best practices for documentation include dating all entries and signing with a full name and professional credentials.
• Specifying units of measurement is critical. The difference between centimeters and inches, or pounds and kilograms, can result in over- or underdosing a patient and can result in potential injury or death.

Appropriate use of abbreviations:

• The cautious use of abbreviations is vital to mitigate the risk of confusion or misinterpretation in healthcare communication. Although acronyms facilitate efficient communication, their misuse can result in significant errors.
• For instance, abbreviating "international unit" as IU instead of writing out the entire phrase may be mistakenly interpreted as IV (intravenous), potentially causing severe medication errors. Precision in abbreviations is paramount to ensure accurate and safe healthcare practices.