Nursing Documentation Tips (2018)

Nursing documentation is a HUGE deal in nursing school. I know you’re worried about if you’re doing it wrong or not, and honestly, you might be making some critical nursing documentation mistakes. 

 

In this video, I’ll walk you through 3 nursing documentation tips that you MUST know about in nursing school. These 3 tips are some common nursing documentation errors that I’ve seen nursing students make, and I don’t want you to be one of them. 

 

So, during your nursing school clinicals, make sure you follow these 3 nurse charting rules: 

 

1. ONLY use abbreviations or acronyms that are approved by your nursing school clinical facility. Your nursing documentation is a legal document, and MUST be thorough and clear enough to hold up in a court of law. 

2. Follow a pattern with your documentation. Always document the same way every time so you don’t forget anything in your nursing documentation.

3. Document right away, as you go. Avoid medication, treatment, and nurse documentation errors when you do your patient charting as you go. 

 

By following these critical nursing documentation tips, you can save yourself a huge headache later by knowing your nursing documentation is thorough and accurate. 

 

 

I HAD to record this video because so many people are doing it WRONG. And you might be one of them. 

 

What is up my friend, Christina here with nursingsos.com and today’s video is all about nursing documentation tips, and things you should and should not do when it comes to patient charting during nursing school. But before we get started, make sure you’re subscribed to this channel and click the little bell icon so you don’t miss out on a future video. 

 

So the first, and arguably the most important nursing documentation tip I have for you today is to ONLY use approved abbreviations or acronyms. But here’s the kicker, there is no standard for acronyms and abbreviations in nursing, it is different facility to facility. So you MUST check with your clinical facility and get their approved list of abbreviations and acronyms BEFORE you use them. 

 

Friend. I’m super serious with this one, there are times when I get up on my soap box and preach to you, and this is one of those topics that just lights my fire. Proper documentation can either make or break your nursing career. 

 

So let’s take an example. Here’s an abbreviation that I’ve seen nursing students write before: B-L- C-L-W -R. 

 

Umm…what? 

 

Okay, so maybe you know what this means. And maybe you don’t. And that’s exactly my point. Because what happens when your documentation is subpoenaed by a court, and you now need to defend your nursing documentation in front of a judge. If that abbreviation isn’t stated as approved by your clinical facility, it is now up for interpretation. And you can bet dollars to donuts that the lawyer is going to shred holes in it faster than you can catch your breath. So my friend, save yourself, and write out your words if there isn’t a facility approved abbreviation or acronym. Yes it takes more time, and yes it’s a pain to do. But it’s a small price to pay for peace of mind, knowing that your documentation is iron clad. 

 

So if you’re with me on this, and are thinking, “Heck yes, Christina just saved my LIFE!” write LOVE in the comments below. I want to hear from you! 

 

So that is tip number one: only use approved abbreviations or acronyms in your nursing documentation. And on that note, I do have a cheat sheet of possible nursing abbreviations and acronyms for you to download. That link is down below, but BEWARE, do NOT use them unless they are approved by your clinical facility. They are just meant for your reference so if you see someone else writing them, you’ll know what they mean. But I don’t recommend using them during your nursing school clinicals if they are not approved by your clinical facility. 

 

Now, tip number 2, is to follow a pattern with your documentation. There’s a reason in nursing we call it the head-to-toe assessment. Because we literally go from head to toe. And this is how I recommend you write out your documentation, from head to toe. When you follow the same documentation pattern as you do when you’re assessing your patient, it’s less likely that you’ll forget something. So each time you document, follow the same pattern, and think back to your nursing assessment. And better yet, as you’re doing your nursing assessment, write things down on your brain sheet if you can’t document as you go. Nursing brain sheets are those cool little half sheets or full sheets of paper with all the boxes, and lab value skeletons, and all that jazz. If you’re not sure what I’m talking about, that’s totally cool, next time you’re at clinical, ask your nurse or your instructor for an example brain sheet so you can see one. They will help you a TON. And good news! A lot of brain sheets do follow the head-to-toe format or pattern, so they do walk you through the head to toe assessment in some way, shape or form. So when you write your assessment data on your brain sheet, you’ll be able to refer to it as you document in the computer or paper chart later. This will also help you remember everything.

 

So that is tip number 2: follow a pattern with your documentation so you don’t forget anything. 

 

And finally, tip number 3: is to document right away. Don’t wait to document on all of your patients at the end of your clinical day. Document as you go. First of all, too much happens during clinical for you to remember everything that you did, so if you wait too long, you will forget some things, even if you tried to write it all down on your brain sheet. Second of all, the healthcare team will need to know what’s going on with your patient in real time, so you really need to document as you go to keep them in the loop. 

 

Here’s an example of how this can go very wrong, 

 

Let’s say you are working with a preceptor or co-nurse on the floor and you have a patient who’s insulin is due before breakfast. You grab their tray and give them their insulin like a rock star nursing student. but you forget to document that you gave it. And let’s say your co-nurse comes in and see’s them eating, checks their chart, and sees that you never gave their insulin, so she gives it. Again. 

 

Ummmm…big deal. HUGE deal. This mistake has huge consequences not only for the patient (because they could literally die), but also for your career as a nurse.

 

So always, always, always be sure to document right away, everything that you do. 

 

And so those are my 3 major tips for proper nursing documentation: Tip number 1: ONLY use abbreviations or acronyms that are approved by your clinical facility. Tip number 2: follow a pattern with your documentation, so you always document the same way every time. And tip number 3: is to document right away, as you go. 

 

If you found these tips super helpful, write LOVE in the comments below to let me know. And of course, make sure to subscribe and click the little bell icon to get notified when we post a new video. 

 

Thanks for watching, friend, now go become the nurse that God created only YOU to be. And I’ll catch you next time on the nursing school show, take care.