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This site is for student nurses or nurses starting out. Letters to a Young Nurse are blog posts written like letters to help you find your way and make your journey as a nurse less difficult. 

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Documentation

Updated: Oct 1, 2023



A former student and new nurse asked for help with documentation. Nursing documentation is an immense topic and one which has been written about ad nauseum. I must admit that I, like the new nurse, hate documentation. I am old school where the narrative note is the most important part of your documentation. Not anymore. Checklists have taken on greater importance. But the narrative note is still important to cover anything not covered in the checklists. As a nurse you have to paint a picture for the reader.

Like any story, you have to answer the 5 W's.

  1. Who did it happen to?

  2. What happened?

  3. Where did it happen?

  4. Why did it happen?

  5. What did you do about it? (what intervention did you use?)

After answering those questions, the nurse must evaluate, after an appropriate amount of time, whether or not the intervention helped the patient. For example, "at 1015 the patient (who) vomited 200cc of undigested food into a basin (what) while lying in bed (where). The patient just finished eating 2 pieces of toast and a bowl of oatmeal. The patient was recovering from gastric bypass surgery and ate too much for her new stomach to hold (why). The patient was given Zofran 4mg ODT one time at 10:20 (what intervention). She was also instructed that she could not eat a breakfast with that much food until her stomach heals from the surgery. She may need to eat smaller amounts more frequently. Twenty minutes later the patient reported cessation of her N/V and verbalized understanding of the quantity of food to be ingested at meals or between meals."(evaluation)."


After reading those sentences did you get a picture like below?



If the Zofran did not work and she did not have any other medications available, then the nurse must call the physician to ask for another intervention. The nurse can write the narrative note and then write a second note after evaluating the intervention as an addendum note. Or the nurse can wait until evaluation of the narrative note is done and then write the note. The "why" of the event should be based on objective data and not on the nurse's opinion. The nurse should never judge the situation, the narrative must be objective, clear and thorough. Never make personal judgements about the situation and do not forget to add appropriate details to prevent anyone else on the team from misinterpreting actions by the nurse for the patient.


Remember the dreaded nursing care plans you had to write? A nursing care plan, simply put, is a picture of the "event" that happened, what the nurse will use to resolve the event and an evaluation of the intervention. We assess, plan, implement, and evaluate every situation with a patient. If the intervention does not work we choose a different intervention and start the process over. For instance, you walk into a patient's room, and they are having trouble breathing. What is your first thought and first intervention? You will not necessarily think, "impaired breathing related to ..." But you should think, let me see about getting some oxygen on, take vitals and contact the physician if needed. If you put the oxygen on and the patient has no further breathing issues, then your evaluation is that the intervention was successful. It doesn't have to be any more complicated than that, but student nurses and new nurses get confused by the "nursing diagnosis" part of the care plan. It is just a different language that has to be learned. Every time you walk into a patient's room you should be making an assessment, planning interventions as needed, carrying out those interventions and evaluating their effectiveness.



Remember the narrative or picture should be thorough, clear and complete. I got "schooled" this week by not providing enough detail in a patient encounter. The patient complained of chest pain, so I added him to the physician's visit list in the morning. My supervisor called the following day to ask why I did not do vitals or an EKG and why the physician was not contacted when the patient voiced their concerns about chest pain. Well, what I forgot to add is the patient had the chest pain for two years which was mild, and exercise induced. He wanted a follow up appointment to check the status of his heart disease. He refused an EKG since his pain was resolved with 1 nitro tablet SL. Those items paint a different picture, right? I added an addendum which explained why an EKG was not done and that this was a chronic issue that was being optimally treated.



Proper and clear documentation covers you, the nurse, if anything bad happens to the patient. And insurance companies want to know that the money being paid to the hospital for services rendered were actually rendered. The insurance company paid a lot of money for a gastric bypass procedure with an expectation that the patient would be safe before, during and after the procedure. Nurses spend more time with the patient than any other discipline and it is our responsibility to ensure that, while in our care, the patient is safe, pain free and is taught what is needed to be safe at their chosen residence upon discharge. Hospital executives want to know that the money paid to the nurse is earned by the nurse. Time spent documenting whether it be passing medications, completing daily checklists, writing narratives or checking labs or other tests is captured every time you log onto the computer.


A recent study by Yen et al. (2018) showed that nurses spend the following amount of time on various activities:

35% documentation

20% care coordination

19% direct patient care

17% medication administration

In the course of an 8 hour or 12-hour day nurses spend more time documenting what was done than the actual doing of the task! If you document as things happen, you will not have to rely on your memory and will not have to spend hours when your shift is finished completing documentation. With rolling mobile laptop carts direct patient care can be documented as you complete the task. By requiring that medications are signed off by having to scan the patient's ID band first, that task is done at the bedside. If you get into the habit of documenting the task, event or activity as you do it you will not have to spend time when your shift is finished documenting. And in this cost-effective and cost-restrictive environment many hospitals and organizations will not pay for overtime for the nurse to finish documentation.




As you can see from the two illustrations more time is spent on documentation than anything else. That is why it is so important that you get it right the first time. Here are some tips learned the hard way from years of having to document different patient conditions.

  1. ALWAYS check that you are documenting in the right patient's chart. You do not want to write a wonderfully concise and complete narrative in the wrong chart.

  2. Answer the 5 questions in your narrative. Even if the checklist covered these items, if it was an unusual event, I would write a narrative note.

  3. Be as clear, concise and thorough as possible without writing a novel.



Yen, P. Y., Kellye, M., Lopetegui, M., Saha, A., Loversidge, J., Chipps, E. M., Gallagher-Ford, L., & Buck, J. (2018). Nurses' Time Allocation and Multitasking of Nursing Activities: A Time Motion Study. AMIA ... Annual Symposium proceedings. AMIA Symposium, 2018, 1137–1146.



(in progress)

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