Documenting Nursing Notes

Required Context

• Note type to be written: admission note, progress note, shift summary, transfer note, incident documentation, telephone order documentation, provider notification note
• Institutional documentation policies (charting by exception vs. narrative, required documentation intervals)
• Previous nursing notes for continuity and trending
• Active care plan with current nursing diagnoses

Pre-Documentation Checklist

• Confirm all interventions have been completed before documenting them
• Verify medication administration records are current
• Ensure all critical findings have been reported to the appropriate provider before documenting the communication

Step 1 — Select the Appropriate Documentation Format

Choose format based on the clinical situation:

1. SBAR (Situation-Background-Assessment-Recommendation) — use for provider notification, handoff communication, rapid response events, and any change-in-condition documentation
2. DAR (Data-Action-Response) — use for focus charting in progress notes tied to specific nursing diagnoses or patient problems
3. Narrative — use for admission assessments, complex clinical situations requiring detailed description, and events that do not fit structured formats
4. SOAP (Subjective-Objective-Assessment-Plan) — use if required by institutional policy; common in ambulatory and primary care nursing
5. Exception-based charting — document normal findings via system defaults; narrative only for abnormal findings, interventions, and changes

Step 2 — Write SBAR Communications

For any change in condition, provider notification, or clinical escalation:

1. Situation: State patient name, room, admitting diagnosis, and the specific reason for communication
   • "Calling about Mr. J. Smith, Room 412, admitted for CHF exacerbation. His respiratory status has acutely worsened."
2. Background: Provide relevant clinical context
   • Pertinent medical history, current treatment plan, recent vital sign trends, relevant lab values, code status
3. Assessment: State your clinical nursing judgment
   • "I am concerned the patient is developing pulmonary edema. Crackles are now bilateral to the mid-lung fields, up from bases only at 0800. SpO2 has dropped from 96% to 89% on 2L NC."
4. Recommendation: State what you are requesting
   • "I recommend increasing oxygen delivery to 4L NC, ordering a stat chest x-ray and BNP level, and considering IV furosemide."
5. Document the SBAR interaction including: time of call, provider contacted, information given, orders received, and read-back confirmation

Step 3 — Write Progress Notes Using DAR Format

For each active nursing problem or significant event:

1. Data: Document subjective and objective data related to the focus
   • Subjective: Patient's own words in quotation marks ("My chest feels tight when I take a deep breath")
   • Objective: Measurable clinical findings (RR 24, SpO2 91% on 2L NC, bilateral crackles at bases, bilateral lower extremity edema 2+ pitting)
2. Action: Document nursing interventions implemented
   • Specific actions with times: "Elevated HOB to 45 degrees at 1430. Applied 4L NC per standing order at 1432. Notified Dr. Patel via SBAR at 1435 — received order for stat CXR and furosemide 40mg IV."
3. Response: Document patient response to interventions
   • "Following furosemide administration at 1450, patient voided 400 mL clear yellow urine by 1530. SpO2 improved to 95% on 4L NC. RR decreased to 18. Patient states 'I can breathe better now.' Crackles decreased to bilateral bases only."

Step 4 — Write Shift Summary Notes

At end of shift or per institutional policy:

1. Priority problems addressed during the shift with current status
2. Significant events including any change in condition, provider notifications, new orders, and procedures performed
3. Assessment summary highlighting any changes from beginning to end of shift
4. Pending items that require follow-up by the oncoming shift: lab results pending, medication times approaching, anticipated procedures, family meeting scheduled
5. Care plan updates made during the shift
6. Discharge planning progress if applicable

Step 5 — Document Provider Communication and Orders

Every provider interaction requires documentation:

1. Telephone/verbal orders: Document the complete order, read back, and verify process (Joint Commission NPSG.02.03.01)
   • "T.O. Dr. Martinez: Furosemide 40mg IV push once now. RB/V by RN J. Torres at 1445."
2. Provider notification of critical values: Time, provider name, value reported, instructions received
3. Provider notification of change in condition: Time, SBAR content, response received, orders given
4. Failure to reach provider: Time of each attempt, escalation chain followed, alternative provider contacted

Step 6 — Document Patient and Family Education

1. Topic taught (medication, procedure, disease management, discharge instructions)
2. Method used (verbal, written, demonstration, video, interpreter-assisted)
3. Assessment of learning readiness (health literacy level, barriers identified)
4. Learner (patient, family member/caregiver — identify by relationship)
5. Evaluation of understanding using teach-back method
   • "Patient able to correctly demonstrate insulin injection technique using teach-back. Correctly identified signs of hypoglycemia. Unable to state when to call provider — topic reinforced, patient able to verbalize on second teach-back."
6. Materials provided (medication guide, discharge instruction sheet, community resource list)

Step 7 — Document Incident and Safety Events

For falls, medication errors, adverse reactions, sentinel events:

1. Objective description of what happened — no opinions, blame, or speculation
2. Patient assessment findings immediately following the event
3. Interventions implemented (vital signs, neuro checks, provider notification, imaging ordered)
4. Patient response to post-event interventions
5. Safety measures implemented to prevent recurrence
6. Reference to incident report by noting "Incident report filed" — do not include the incident report number or details of the report in the medical record (per risk management guidelines)

Checkpoint B — Documentation Review

Completeness Verification

• All interventions documented with times
• All provider communications documented with SBAR elements
• All medication administrations verified against MAR
• All patient/family teaching documented with evaluation
• Assessment data supports documented nursing diagnoses
• Shift summary captures all significant events

Legal and Regulatory Verification

• Documentation is contemporaneous (charted in real-time or within institutional policy timeframe)
• No late entries without proper "Late Entry" notation per institutional policy
• Corrections use single-line strikethrough with initials, date/time, and "error" notation (no erasures or white-out)
• All entries are signed with name, credentials, date, and time
• No prohibited abbreviations per Joint Commission "Do Not Use" list

Quality Audit

• Notes use objective, measurable clinical language (numbers, scales, direct observations)
• Subjective data is attributed to the source and placed in quotation marks
• All time-sensitive events include specific times (24-hour clock per institutional policy)
• SBAR format used for all provider communications
• Critical value reporting documented with read-back confirmation
• No gaps in documentation that create an inference of absent care
• Documentation supports the current care plan and nursing diagnoses
• All notes are legible and complete (electronic charting: no incomplete flowsheets)
• Patient privacy maintained — no identifiable information in non-secure communications
• Documentation would withstand legal scrutiny: complete, accurate, timely, and objective

Guidelines

• ANA Standards: Standard 1 (Assessment documentation), Standard 5 (Implementation documentation), Standard 6 (Evaluation documentation) — all require contemporaneous, accurate records
• CMS CoP §482.24: Medical records must be accurately written, promptly completed, properly filed, and accessible
• Joint Commission: NPSG.02.03.01 (reporting critical results), IM.02.02.01 (medical record content requirements)
• HIPAA: Documentation must comply with privacy rule; minimum necessary standard applies to verbal and written communications
• Legal standard: The medical record is a legal document; courts apply the presumption "not documented = not done"; late entries are admissible but given less weight
• Prohibited abbreviations: Never use U (write "units"), IU (write "international units"), Q.D./Q.O.D. (write "daily"/"every other day"), trailing zeros (write "1 mg" not "1.0 mg"), lack of leading zeros (write "0.1 mg" not ".1 mg"), MS/MSO4/MgSO4 (write "morphine sulfate" or "magnesium sulfate")
• Timeliness: Document as close to the event as possible; institutional policy typically requires documentation within 1–2 hours of the event; critical events documented immediately
• Objectivity: Never document personal opinions, judgments about other staff, or defensive language ("charting for the lawyers"); document facts and clinical findings only