Proper Nursing Documentation (Effective 5/6/2020)

FOR RNS: OASIS

1. Every diagnosis that is active should have a documentation on why it needs to be

managed. Ex. Patient has HTN, BP ranges: 120 – 210/ 70-90’s. Patient has a new
medication for HTN requiring management/ assessment of effectiveness.
2. Pain – Please document what dx is causing pain. Ex. Wound / Arthritis/ Lumbar stenosis
3. Avoid abbreviations on the medication profile to avoid “Unacceptable abbreviations”
4. Wound description should be complete and clear

FOR RNS: CONSENTS

1. Consents and other documents during SOC should be completed, signed and dated.
2. Under the consent’s SERVICE always write 100% under the insurance pays, and 0%
under the patient’s pays.
3. Complete advance directive appropriately and correctly.

FOR RNS and LPNS: NURSING NOTES

1. Complete every system assessment. Assessment that shows CHANGE IN CONDITION /

Vitals signs outside the parameter should be called to the MD and document that MD
was made aware. Order is not expected.
2. Negative findings should be addressed every time.
3. Update medication profile via MD order for NEW, CHANGED, DC’d medications.
4. All teachings should start on why a teaching is needed.
5. All teachings should be based of the POC. If not in the POC, an order will be necessary
6. Interventions checked should have a detailed documentation under details.
7. Wound care should be stated completely, follow how the MD order is stated.
8. PATIENT RESPONSE should include an objective measurement to show progress
ex. Patient verbalized 100% understanding. Patient had 3/10 pain during wound care.
Patient’s capillary refill remained less than 3 seconds after compression dressing was
applied. Avoid: Patient tolerated procedure well.
9. PLAN FOR THE NEXT VISIT – should be based on the current or previous SN visit, use
objective measurement. Ex. Patient continue to have elevated of BP based on today’s BP
level, SN to continue to assess and manage HTN. Avoid: To continue POC
10. WOUND CHART – 1 WOUND CHART EVERY WEEK – complete all questions in the wound
chart. Measurements should also always be in this format: L x W x D. Tunneling and
undermining should be located using clock method (ex. 3 o’clock 3 CM , 4-7 o’clock: 4
CM. most wounds have depth, document why no depth recorded or if covered by scab,
eschar, slough that is why no depth noted ex. 1x3xeschar, / 1.5x4xunable to measure
depth due to small opening. ONLY pressure ulcers should be staged.
11. Fall, Grievance, injury, med errors, New Infection- forms should be completed as they
occur, access the forms by clicking the date of the incident in the calendar.
12. Missed visits: No order needed. Please document why pt was not seen, and that MD
was made aware of the missed visit, document if MD gave new order or no order given
related to the missed visit.