There are a lot of things that you need to be documenting throughout the day. Primarily your documentation will consist of charts for patients, though you’ll also need to document phone calls with patients, doctor’s verbal orders, and anything out of the ordinary that has happened throughout your shift. Doing so will help protect you as an employee and will ensure that proper care is offered to patients in need.
To help you perfect your documentation skills, try following the SOAPIE method.
Subjective – reports and documentation should include what the patient says. This should include any perceived pain, symptoms, medical history, or allergies. Ask a lot of questions and be sure to record answers correctly. Be as thorough as possible.
Objective – record what you, as a nurse, observe in the patient. The patient may not always know what to check on themselves and with your expertise, you’ll be able to fill in any gaps.
Analysis – This part of documentation requires that you make an initial diagnosis for the patient. This step cannot be completed properly if the first two steps weren’t taken. Ultimately, the analysis portion of documentation is a combination of what information the patient gives and what the nurse is able to observe. Just like a mathematical equation, you need both parts to come up with the correct answer.
Plan – When you’ve reached an initial diagnosis, the nurse needs to make a plan for upcoming interventions. Here is where you will record what you think the patient needs to improve. This could be medication, exams, blood work, etc.
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Implementation – Once decisions have been made about how to proceed with a patient, you’ll need to record what was actually done, even if it differs from the recorded plan. In consulting with other nurses or physicians, your implementation might change from the plan, and that’s ok. The important thing is to document everything in this step.
Evaluation – Finally, you’ll need to record the outcomes of the interventions that were taken. Test results should be included here as well as any reports from other departments related to your patient. This section should be inclusive of everything that has gone on with the patient. If the evaluation reveals that an intervention did not work, you’ll need to back up a few steps and start over with planning. Repeat the last few steps as necessary until a satisfactory outcome is reached.
When Should I Document?
When you should document depends a bit on what type of documentation you’re talking about. For some documentation, like for fall or physical assessments, you’ll only do this once a shift. However, other assessments, such as for pain, should be done regularly throughout the shift as needed. Other regular documentation should be taken upon intake, at the change of a shift, when a patient is discharged, when they return from a test or procedure, and any time a new complaint arises.
While it can be difficult to set aside time to document when there are patients in need of your care, it is a crucial part of good nursing and offering quality patient care. If you’re having a hard time remember to document or setting aside time for it, try to remember that the reports serve as a sort of road map that will let you and other nurses know what needs to come next for that particular patient. It’s a lot easier to read a chart and know what to do than it is to question the patient or other nurses for guidance