5 Ways to Cut Down on Documentation
Be afraid. Be very afraid of a nurse who loves to document. If you are a nurse who loves to document, please navigate safely to another website and never, ever come back here. For the rest of you, here are five tips that will shorten the time you spend documenting, increase the chance that your agency will be paid and keep you out of regulatory hot water.
- Don’t be redundant. Do you like talking to people who repeat themselves? Do not elaborate on ordinary information that is part of the flow sheet component of your visit note. Example: Pt awake, alert and oriented for visit. Denies pain.(Assuming you already checked the boxes for neuro status and pain on the flow sheet.)
- Step away from the computer when writing care plans. The care plan should address the diagnoses, medications, out of range parameters and teaching. And not much else. Care plans cluttered with orders to address ‘just in case’ situations are useless. Example: A patient with no cardiac history is admitted for diabetic teaching and has, ‘teach signs and symptoms of an impending MI’ on the care plan. Why not reserve that order for people who have heart disease?
- If you attach a teaching guide to your notes or upload one into the computer, documentation can be complete by simply stating that teaching was offered according to sections A and B of attached Diabetic Care Plan. (Name the care plan and include the source – ADA, NIH, etc.)
- Pasting teaching material into electronic documentation does not save time. Every sentence must be read and considered in light of your patient. If it is not reviewed, you will end up with documentation that reads something like, ‘Taught patient to avoid contact sports while taking medication’. If a patient can play contact sports, they might not be homebound. There are also visit notes that include teaching for men to notify their physicians should they become pregnant. This would be very difficult to argue in an appeal.
Documenting everything the patient denied is not useful. In fact, it paints a picture of a patient who might not need services. If your patient denies falls, shortness of breath, chest pain and difficulty with urination, ask yourself how important that information is to your individual patient. The denial of falls would be important to patients admitted for therapy because of a history of falls. It may not be relevant to a patient that is chairbound admitted for diabetes.
Cutting down on the clutter leaves clean documentation where it is easy to find the information needed to determine payment. It takes much less time to document leaving you with more time which can feel like a luxury on some days.
4 Comments Post a comment
Regarding your first item: The problem is sometimes one of experience. E.g., I make a few entries in the flowsheet area re: pain. If min/mod pain is a normal and controlled issue for the client that is all that is needed. However, if pain is one of the areas we are addressing with the patient, or a radical change from their normal, or a new issue with them, then I need to address it in the narrative portion of the note. An experienced nurse learns to tell the difference. Unfortunately, this is also counter to how some were taught in Nursing School.
You are correct in that experience is needed to discern the difference at times. New pain, worsening pain, etc is obvious. Pain that was parent but went away may or may not be worth expounding on in documentation. When in doubt, document. What will help is for clinicians to ask how relevant the part of the assessment is before they chart,
It is habit for many of us to start each note with a recap of vitals and pain, etc. even though these elements are on the flow sheet. I would rather see something ‘interesting’ and specific to the patient. Consider, ‘pt awake, alert and oriented. Denies pain. BGL 142′ vitals inserted here. Taught side effects of meds. Pt/cg verbalized understanding in unison’. Just kidding about the unison part.
Compare that to, ‘pt appears uncomfortable. Complains of pain rated 4 to stomache area. Says it ‘isn’t bad’ but gets worse on ambulation. MD notified. Reviewed meds with MD. New order received for gutcomfort pills and f/u visit tomorrow. Teaching on diabetes delayed until pr feeling better.
The second example not only focuses on the patient but explains what was done for the patient and why the prior orders were not complete.
New nurses will have trouble with this for a while but I would rather see them try and make a few mistakes than recite all the unremarkable parts of an assessment! You?
Part of it is a mind set and breaking habits.
Absolutely! I would also say that I used to be that person who wrote too much. I followed the Head To Toe charting that we did at the hospital for report. In the process, I put in way too much info. It was complete and would stand up to any audit for regulatory compliance, but people reading it would get glassy eyed! Now, it’s short and sweet.
I know how hard it was for you to admit that you used to be ‘one of them’. They say admitting the problem is the first step and apparently, your first step has taken you far. My hat is off to you.