education extra
Documentation skills
for nursing students
By Diana L. Goodwin, MSN, RN
Documentation allows for clear com-
munication between healthcare team
members; provides a full accounting of
patient care to support reimbursement,
ensure quality care, and reduce errors;
can be used as evidence in legal mat-
ters; and generates data for research
and quality improvement initiatives.
The challenge for nurse educators is
ensuring that graduate nurses not only
have the necessary skills for effective
documentation, but also understand
the risks of poor documentation to
their patients and themselves. This
challenge is compounded by a lack of
recent literature on generating effective
documentation.
This article reviews the rationale for
documentation and its essential compo-
nents, and offers a memory aid to assist
students in developing effective docu-
mentation skills.
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Best practices
The expectation is that all documentation
should be clear, concise, comprehensive,
accurate, objective, and timely. Nursing
organizations have developed position
statements and guidelines that give a
broad overview of what information to
include, how often documentation should
be completed, and how to format entries
and errors. Facilities supplement these
guidelines with policies delineating spe-
cific documentation requirements, stan-
dard definitions of assessment findings
considered within normal or expected
limits, expected intervals for assessments,
and time frames for completing docu-
mentation. Position statements and docu-
mentation guidelines include:
• American Nurses Association’s (ANA)
2009 position statement on the electronic
health record (EHR) (www.nursingworld.
org/practice-policy/nursing-excellence/
official-position-statements/id/electronic-
health-record)
• ANA’s 2010 Principles for Nursing
Documentation (www.nursingworld.
org/~4af4f2/globalassets/docs/ana/ethics/
principles-of-nursing-documentation.pdf)
• Centers for Medicare and Medicaid
Service’s 2007 Evaluation and Manage-
ment Services (www.cms.gov/Outreach-
and-Education/Medicare-Learning-
Network-MLN/MLNProducts/Downloads/
P AND P STOCK / SHUTTERSTOCK
eval-mgmt-serv-guide-ICN006764.pdf)
• Technology Informatics Guiding Edu-
cational Reform’s 2009 TIGER Informatics
Competencies Collaborative Final Re-
port (http://tigercompetencies.pbworks.
com/f/TICC_Final.pdf).
For example, the ANA provides guid-
ance and recommendations not only
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for nurses, but also facilities, patients,
healthcare systems, and educators. The
ANA outlines the components of proper
documentation and addresses institution-
al responsibilities. Nurse input into the
design of EHRs and participation in trials
of new systems is encouraged.
The ANA also recommends that facili-
ties ensure staff members have adequate
training to become proficient in using
documentation systems. Additionally,
facilities are urged to provide staff with
adequate time to complete effective docu-
mentation. Including nurses in decision-
making related to EHRs, providing nec-
essary training, and factoring the time
needed for documentation into staffing
decisions ideally reduces the risk for poor
documentation practices while increasing
the quality of patient care and communi-
cation between healthcare team members.
As stated previously, documentation
serves many purposes, but the two uses
that garner the most attention are the legal
and patient safety aspects. The patient’s
EHR is considered a legal document and
can be used in a court of law to exemplify
the quality of patient care, or its lack.
The EHR, in effect, becomes an impar-
tial witness to the care delivered to each
patient by the healthcare team. For this
reason, documentation must be exacting
in its accuracy. Only actions completed
or witnessed by the person documenting
should be included. Subjective statements
and opinions shouldn’t be included in
the EHR because they aren’t quantifiable.
Accurate, complete, objective documenta-
tion protects not only the patient, but also
the healthcare professional.
Correct documentation also ensures
patient safety. The EHR serves as a means
of communication between healthcare
team members from different shifts and
disciplines. It’s difficult to include every
event occurring during a 12-hour shift
at the patient handoff report. As a result,
it isn’t unusual to see nurses review the
documentation from previous shifts to
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compare their findings with earlier assess-
ments, confirm a suspected trend in vital
signs or lab values, or verify that recent
orders and appropriate notifications have
been completed. Complete, concise, and
accurate documentation allows needed
information to be located quickly, decreas-
ing the likelihood that complications will
occur.
Documentation should communicate
assessment data, changes in patient condi-
tion, interventions and treatments pro-
vided, response to treatment, all patient
transfers to and from different areas of
care, and communication with members
of the healthcare team and family. Assess- Making
ment data should include not only the decisions
results of the physical exam, but also vital
signs, lab values, and results of diagnostic
regarding
procedures. Facilities dictate the mini- what and
mum frequency of this type of documen- how much
tation. When a change in patient condition
is noted or suspected, additional assess-
information to
ment and documentation are warranted. include can
Interventions and treatments provided be a source
during patient care by all healthcare
team members should be included, as
of student
well as the patient’s response to these frustration.
activities. All actions performed by the
nurse should be documented in detail.
Additionally, nurses should document the
occurrence of actions performed by other
healthcare team members. The individual
performing these activities will complete
detailed documentation of the interven-
tion, whereas nurses will document when
they occurred, who completed them, and
the patient’s response. For example, a
dietitian or wound care nurse will detail
his or her visit in the progress notes; the
nurse will note the time of the visit and
any orders received so nurses during sub-
sequent shifts will be aware of additional
orders and who to contact for questions or
changes in patient condition.
A timesaving feature of the EHR is
the ability to document by exception.
Before the implementation of EHRs,
documentation included all findings,
March/April 2019 Nursing made Incredibly Easy! 17
 education extra

Documentation quick guide

When Start your entry with the time and date to provide a chronological record
of care.
Materials Include the size of equipment, the amount of medication administered,
etc.
What Describe or identify the intervention completed. If completed by some-
one else, name the person completing the procedure.
How/why Provide the rationale for the intervention and ensure proper technique. If
the intervention is a sterile procedure, include this in documentation.
Measure/assess Use objective language to describe your observations before, during,
and after the intervention.
Patient response Include objective observations and/or patient statements describing
response to treatment.
Late entry Late entries are allowed within a specified timeframe, usually 24
hours. Enter the current time and date and the words LATE ENTRY,
followed by the entry. Example: 1/7/18 1945 LATE ENTRY: 1/7/18
1400 I.V. site infiltrated. Unable to gain additional access after four
attempts. Dr. Fraser informed. New orders: Central line placement by
anesthesia.______________F. Friend, RN
Error If an error is made, draw a single line through the incorrect informa-
tion and initial the strikethrough. Don’t use erasable pens or correction
tape or fluid. Example: 1/7/18 0658 2 mg MSDG morphine adminis-
tered I.V. push for pain rated 8/10. I.V. site warm, dry, no infiltration
noted._______________F. Friend, RN

normal and abnormal. Documenting by
exception is designed to save time by
allowing members of the healthcare team
to note only findings that differ from the
expected during an exam or procedure. If
the assessment findings match the facil-
ity’s predefined designation of normal
or expected, within normal limits (WNL)
may be selected and no further informa-
tion for that section is required.
It’s vital to be familiar with the facil-
ity’s definitions for each area of the EHR
to ensure accuracy in documentation.
As helpful as the WNL feature can be, it
presents a problem for educators when
instructing students about documentation.
Just as the normal range of lab values can
differ slightly between facilities, the defini-
tion of WNL will mirror these slight varia-
tions. Educators test lab values in accor-
dance with the school’s chosen text while
cautioning students to expect variation in
their clinical setting and emphasizing the
need for situational awareness. Instructing
students in the appropriate use of WNL
should be addressed similarly.
Without an EHR
The 2009 American Recovery and Rein-
vestment Act required all healthcare facili-
ties and providers to incorporate EHRs
into patient care by January 1, 2014, to
continue receiving their existing level of
reimbursement for provided Medicare
and Medicaid services. As a result, tradi-
tional paper documentation is virtually
unknown to many nursing students and
new nurses. Without the EHR to prompt
what information to include, students
often include either too much or too little
information. Students can undervalue
the need to practice documentation skills
in their reliance on available technol-
ogy. When working with students, it’s

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important to emphasize that EHRs won’t tape should never
always be available. be used in patient memory jogger
In a study of downtime errors, it was records. When sign- Documentation memory aid
found that when an EHR is functional 99% ing a written order,
of the year, facilities are still without EHR a single line should
capabilities for 3 days and 15 minutes be drawn through
annually. In the case of natural disasters or the remainder of

hy
ia ls

W ha t
fires, healthcare facilities can be without the row before the

How/w
Mater
EHR access for days or weeks and docu- signature to prevent

en
menting must be done on paper. And it unauthorized addi-

Wh
isn’t only natural disasters and environ- tion of information.
mental hazards that pose a threat to EHRs. Facilities will have

ss
Recently, cyber-attacks have become more clear expectations

e
/a s
ss
re s e
commonplace. During this type of attack, regarding late en-
Patient

su en
a ransomware virus encrypts all hospital tries; nevertheless, response

ea 4 s
data until a ransom is paid. Hospitals may each delayed entry
need to stop using the EHR for days while should be given

protective systems are put into place.
Many hospitals have physician portals
in place so providers can access patient
information from their homes and mobile
devices. When systems are down for
any reason, providers must rely on other
healthcare team members to keep them
informed in a timely manner and increase
the number of rounds or time spent round-
ing. Communication between units, the
lab, pharmacy, and other departments can
also be delayed. Orders and results must be
faxed between locations, increasing the risk
of errors in both ordering and reporting.
Facilities will likely have downtime
flowsheets to record vital signs, medica-
tion administration, and physical assess-
ments; however, documentation of events
and treatments must be made indi-
vidually by hand. For these reasons, it’s
imperative that students understand the
components of effective documentation,
regardless of the method.
Documenting with students
Written errors, signatures, and forgotten
information are the simplest aspects of
documentation to address with students.
Miswritten information should have a
single line drawn through, followed by
the initials of the documenting nurse.
Erasable pens and correction fluid or
M
the current date
and time, identi-
fied as a late entry,
and followed by
the information
that would’ve been
provided had the entry been timely (see
Documentation quick guide).
Providing instruction regarding what
information to include when document-
ing an event or intervention is more
challenging. Making decisions regard-
ing what and how much information to
include can be a source of frustration for
students when practicing documentation
during various activities. Memory aids
can be effective tools to assist students
in the decision-making process. For
example, use of a color-coded keyword
technique in which each piece of needed
information is assigned to the fingers
and palm of the hand provides a check-
list to ensure the inclusion of all neces-
sary data (see Documentation memory aid).
Assigned categories of information
include:
• when (pinky finger)
• materials (ring finger)
• what (middle finger)
• how/why (pointer finger)
• measure/assess (thumb)
• patient response (palm).

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 education extra
Each entry begins with the time and
date (when) to establish the timeline of
care. Next, document the materials used for
the intervention (materials). This includes
information such as I.V. catheter size, mate-
rials used for a dressing change, or the dose
of an as-needed medication given, to name
a few. Third, describe or name the interven-
tion (what). Fourth, include the rationale
for the intervention and any special posi-
tioning or method used, such as high Fowl-
er position or sterile technique (how/why).
Next, provide appropriate postintervention
assessments or measurements (measure/
assess). Finally, note the patient’s response
to the intervention (patient response).
Color-coding allows students to visualize
how each portion works together to create
a complete, concise entry.
Do’s and don’ts
As stated previously, correct documenta-
tion is accurate, concise, timely, legible,
and provides precise information such
as “50 mL of serous drainage” versus “a
small amount of drainage.” However,
there are a number of ill-advised prac-
tices that students are likely to encounter
at some point during clinical experiences
(see Documentation do’s and don’ts). One of
the most common habits to avoid is the
Documentation do’s and don’ts
DO DON’T
• Include date/time of entry • Use shortcuts and work-arounds
• Ensure the accuracy and (such as copy/paste and override
precision of your entry functions)
• Document care completely • Delay documenting until the end
• Document care as close to the of shift; this can cause missing
time it occurs as possible information
• Ensure documentation is for the • “Pre-document” or document
correct patient activities before completion
• Include patient comments and • Include subjective language
actions for further clarity such as “fair,” “appears,”
• Follow established professional “small,” etc.
and institutional guidelines for • Document conflicting information
documentation (such as 2+ pedal pulses on a
below-the-knee amputation)
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use of copy/paste. It isn’t uncommon for
nurses to enter their initial assessment in-
formation and copy/paste all remaining
assessments for the day, scrolling through
quickly for updates or changes. Often,
this copy/paste function can be used
when caring for the same patient on con-
secutive days by copying the last assess-
ment of the previous day. Although the
intention is to save time, it’s easy to miss
changes in patient condition or include
care provided at a previous time.
Other practices relating to timeliness are
“pre-documenting” and delaying docu-
mentation until the end of the day. Pre-
documenting is documenting care before it
occurs; in essence, documenting something
about to be done. Unexpected findings that
aren’t added to the pre-documentation can
result in inaccuracies. Unplanned events
can prevent the care from taking place,
leading to falsified care. Conversely, delay-
ing documentation until the end of the
day often results in the omission of details
relating to care and patient condition, and
may delay recognition of a negative trend
in condition.
One last caution for students is to
avoid “autopilot” documentation. In
their desire to document quickly for all
assigned patients, nurses can hastily docu-
ment assessment information from habit
rather than observation. We’ve all heard
about, or seen, the medical record indi-
cating pedal pulses are present on a leg
with a below-the-knee amputation. This
contradictory documentation leaves the
healthcare provider and the facility legally
at risk in the event of a negative outcome.
Wrap-up
Students often have challenges with
learning how to effectively document.
As educators, we need to develop
methods to ensure that students not
only understand the larger issues of ac-
countability related to documentation,
but also the basics of how to notate er-
rors and what to include in an entry.
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Dismissing documentation as a nuisance
that can be abbreviated when demands
on time become overwhelming increases
the risk to patient safety. Accurate docu-
menting is quality patient care. ■
REFERENCES
Alfaro-LeFevre R. Applying Nursing Process: A Tool for
Critical Thinking. 7th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2010.
American Nurses Association. ANA’s principles for nurs-
ing documentation: guidance for registered nurses. 2010.
www.nursingworld.org/~4af4f2/globalassets/docs/ana/
ethics/principles-of-nursing-documentation.pdf.
Hamilton BR, Harper M, Moore P. Nursing Documentation
Using Electronic Health Records. New York, NY: McGraw-
Hill Companies, Inc.; 2011.
Mannion C. Three US hospitals hit in string of ransom-
ware attacks. NBC News. 2016. www.nbcnews.com/
tech/security/three-u-s-hospitals-hit-string-ransomware-
attacks-n544366.
Putnam A. Mnemonics in education: current research and
applications. Transl Issues Psychol Sci. 2015;1(2):130-139.
www.NursingMadeIncrediblyEasy.com
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Schaar GL, Mustata Wilson G. Evaluating senior bac-
calaureate nursing students’ documentation accuracy
through an interprofessional activity. Nurse Educ.
2015;40(1):7-9.
Schneider JH. Best practices on reducing errors during
downtime. HIMSS16 Conference & Exhibition. 2016.
www.himssconference.org/sites/himssconference/files/
pdf/HITS%206_0.pdf.
Stevens S, Pickering D. Keeping good nursing records: a
guide. Community Eye Health. 2010;23(74):44-45.
Tower M, Chaboyer W, Green Q, Dyer K, Wallis M.
Registered nurses’ decision-making regarding documen-
tation in patients’ progress notes. J Clin Nurs. 2012;21(19-
20):2917-2929.
University of Southern Florida. Federal mandates for
healthcare: digital record-keeping requirements for
public and private healthcare providers. 2018. www.
usfhealthonline.com/resources/healthcare/electronic-
medical-records-mandate.
Diana L. Goodwin is an Instructor at Texas Tech University Health
Sciences Center School of Nursing in Lubbock, Tex.
The author has disclosed no financial relationships related to this
article.
DOI-10.1097/01.NME.0000553096.31950.4b
March/April 2019 Nursing made Incredibly Easy! 21