Chapter 6: Documentation: Charting Your Care

About the Author:
Mark Aquino is a registered nurse in California with a Bachelors of Science in Nursing and Masters of Health Administration from West Coast University. He has at least 5 years of experience in the front lines as a visiting nurse in home health and hospice in direct patient care. He is author of OASIS NINJA: A Home Health Nurse’s Guide to Visits, Documentation, and Positive Patient Outcomes. This guide provides nurses with the information they need to provide quality care to their patients in the comfort of their own homes. He also writes books about how to live a good life and how to improve yourself on a daily basis such as Self Help Transformation: An Evidence-Based Approach to Personal Transformation for Mental Health, Physical Fitness, Relationships, and Career. You can also find all his books here. Learn more at

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The Importance of Documentation and Charting for Nurses

Documenting and charting may seem time consuming and tedious, but they are integral components of nursing. Documentation ensures continuity of care while simultaneously creating communication channels between healthcare professionals – especially across disciplines and facilities.

Poor or incomplete documentation can expose nurses and healthcare facilities to liability risks, so let’s explore its importance and why nurses must do it properly.

Patient Safety

With medical technology constantly advancing, patient safety must become the top priority to avoid adverse health outcomes. While most doctors and nurses strive to keep patients safe, errors do occur and proper documentation can help reduce or mitigate their impact.

Example: if a nurse forgets to document that she checked the refrigerator temperature before giving a patient medication, that patient could suffer an allergic reaction because it wasn’t administered as directed. Furthermore, should further health complications arise that need medical treatment in the future and require further visits, having such documentation available will provide more complete picture than verbal descriptions alone would.

Proper documentation not only enhances patient outcomes, but it can also shield nurses from legal liabilities. When considering malpractice lawsuits against physicians, judges and juries rely on documented evidence in the case to decide whether they were negligent or not; when errors lead to significant harm for a patient, the judge or jury can draw an association between lack of documentation and negligence on behalf of physicians.

Nurses must ensure they accurately document observations regarding patient conditions, recording any orders for treatment. This will help to ensure that if any lawsuit arises against them they receive adequate care.

Effective charting can also aid in the prevention of healthcare-acquired infections. Such infections may arise during hospital stays or home treatment and include catheter-related bloodstream infections, surgical site infections and various other infections. Many times these infections result from delayed diagnoses due to poor communication between healthcare team and patient or inadequate infection prevention practices, equipment malfunction or unclean environments in hospitals or private medical offices.

To improve patient safety, all healthcare staff should receive training on how to effectively record observations and communicate effectively among themselves. Preferably, such a session would take place before any employee begins work with any particular employer. Furthermore, medical organizations must create clear policies and procedures for handling complaints from patients or family members regarding patient safety issues.

Patient Outcomes

Patient outcomes are an integral component of nursing practice that can have an impactful influence on clinical practice, healthcare policymaking and patient satisfaction. Outcomes can be measured in various ways and evolve over time; some common measures of outcomes include patient functional status, safety concerns and satisfaction with care – patients can even participate in their own outcome measurement through patient reported outcome measures (PROMs).

Documenting patient outcomes (or outcomes) is an integral component of nursing. Doing so allows nurses to ensure patients receive optimal care, meeting all their needs while helping determine if effective care has been provided by themselves and by others. Furthermore, documentation helps protect nurses against medical malpractice lawsuits by showing all steps were taken by themselves in meeting patients’ needs.

Nurses must meticulously record every aspect of a patient’s health, such as symptoms and progress. Maintaining clear records is crucial for maintaining continuity of care, determining clinical reimbursement rates, avoiding malpractice claims, facilitating communication among healthcare professionals both within the same facility as well as across disciplines, and mitigating liability risk to both individual nurses and hospitals.

Documenting all activities undertaken during their shift is especially essential for nurses working on the floor, since it can be hard to recall everything that transpired throughout each shift. Therefore, having a reliable system of record-keeping that allows easy updating and searching will help ensure no details are missed and information can always be easily found when needed.

While conventional metrics, such as cost, volume and structure can provide useful assessments of healthcare organizations’ performance, they should also take into account outcomes important to patients. This requires shifting away from process metrics towards outcomes-focused measures – which may prove challenging for clinicians and payers accustomed to measuring and reporting process data.

Documenting healthcare effectively for patients is crucial to providing superior healthcare services. This involves recording their initial condition, medications prescribed and response to therapies or procedures as well as their nursing plan, evaluating effectiveness of interventions and communicating with other providers.

Legal Issues

Documentation and charting in nursing are integral parts of medical records, according to Nicole Walker, MSN, RN, CCHP-A of Bryant and Stratton College and Concordia University in Wisconsin. Documented charts are seen as essential against legal action or claims of malpractice according to Walker.

Documentation refers to keeping records of patient signs, symptoms and responses to physician orders, treatments or interventions. Documentation is an essential element of nursing work and nurses are legally obligated to document all information for legal compliance purposes. A nursing record serves as the main resource for measuring quality healthcare provision across hospitals, clinics or physicians’ offices.

Records in court proceedings tend to be seen as more objective and impartial than verbal testimony in medical negligence cases due to being easily verifiable and substantiated – which explains why plaintiff’s attorneys will often use lack of documentation as evidence supporting their malpractice claims.

Effective nursing notes tell a patient’s story clearly and should be easy for any health care professional to comprehend. Unfortunately, many new nurses do not receive sufficient training on how to document patient encounters properly – this may be caused by various factors like COVID-19 reducing clinical placements for nursing students as well as employer misrepresentations of training needs for this area of nursing practice.

Nurses working outside a hospital or clinic should carry individual professional liability insurance to protect against potential malpractice claims. This policy must also cover any moonlighting activities they engage in, such as providing consultation services for public health agencies or private insurance companies, or performing activities either for pay or as volunteers. Policy should include services provided through nursing education programs, telepractice or providing telephone/video conferencing medical advice directly to patients, internet or mobile app services they offer patients as well as any online or mobile apps used by the provider – this course provides 1.5 CE hours! Instant Access Online Video Training Provides Essential Documentation and Charting Tips for Nurses


As a newly licensed nurse, you may feel secure about your ability to place an IV and take vital signs, but may be overwhelmed by paperwork. Nursing documentation can be an intimidating challenge as you gain more knowledge of patients’ medical histories and care plans; even with good intentions it’s easy for mistakes that could prove costly for patients. Luckily many best practices for charting are easy enough to implement into daily routines without much extra work needed from nurses.

Maintaining accurate records is one of the primary goals of nursing, yet some practitioners struggle to stay on top of it all. Newcomers to healthcare can find this task especially daunting and cumbersome; according to one recent survey, more than half of community nurses who responded felt overburdened by clinical and organizational documentation processes; this burden is particularly evident among smaller rural hospitals.

Nursing documentation is vital, serving as a record of your patient’s medical history and serving various purposes like regulatory or disciplinary proceedings, coroner investigations or even supporting positive patient outcomes. Documentation supports both nursing practice and positive patient outcomes in equal measure.

Documenting every aspect of patient care will help protect you against future liabilities. Being clear and precise with your notes will be important, but don’t neglect any vital details!

Remember to proofread and spellcheck your work thoroughly. Even minor typos could turn against you in court proceedings if the matter goes that far.

Do not be intimidated to seek advice from other nurses on documenting. Your peers have likely been practicing nursing for some time and can offer their expertise for charting. Their advice could also help prevent common errors from being made in charting.

Types of Documentation Formats for Nurses

Documentation in nursing is an integral component of nurse responsibilities. Documents protect nurses against liability lawsuits while simultaneously increasing patient safety.

Nursing notes are used by payors for reimbursement of services, reviewed for research purposes and assessed to ensure quality assurance. There are various formats used by nurses when creating documentation of services provided. However, this book this focus on SOAP Notes and PIE Notes.

SOAP Notes

SOAP Notes are written documents used by healthcare professions to track patient/client interactions. Psychologists and psychiatrists who work in mental health settings frequently employ SOAP Notes; however, any provider can use them for recording patient encounters clearly and efficiently. SOAP stands for Subjective, Objective Assessment Plan.

The subjective section documents a patient’s anamnesis (medical history). This includes any reports or comments from them, their family members and care providers as well as any physician impressions based on behavior: for instance if they appear agitated or have difficulty answering questions it is essential that this be noted in writing.

Next, an objective section documents the physical examination and diagnostic tests conducted on the patient. This should include taking vital signs or measurements; receiving lab or diagnostic test results; noting any abnormalities during exam; as well as documenting potential treatment options including medications, referrals or follow-up appointments that might be considered by their physician.

Assessment section. Finally, assessment is where physicians diagnose patients based on information gleaned from objective and subjective sections. They must do this with as much clarity and specificity as possible so that other medical professionals understand exactly what diagnosis has been made and the proposed course of treatment.

Assessment should also account for changes in patient status or progress over time, which is especially pertinent to behavioral and addiction therapy treatments, where conditions frequently evolve over months or even years. Documenting consistently can help minimize medical errors that arise when different doctors take conflicting or incomplete notes, which has been found to be one of the major contributors to malpractice claims. Documenting patient data through SOAP notes simplifies sharing it between healthcare providers. This can reduce redundant testing and imaging procedures, enhance communication among providers, and help enhance patient outcomes. It may also help decrease communication failure risk which has been cited in 37% of high severity injury malpractice cases. Its advantages for mental health practitioners are readily apparent.

PIE Notes

PIE Notes are mental health progress notes that capture the person-in-environment perspective, an integral component of holistic mental health care. PIE Notes can document a client’s background, their therapeutic interactions and environmental influences that could affect their mental wellbeing, helping foster collaboration and continuity across multiple settings.

Mental health professionals utilize various documentation formats, but PIE Notes offer an efficient and simple method for documenting psychotherapy sessions and progress for clients. PIE Notes are easy to learn, condensing information into three concise sections which address each client’s presenting problem, what was attempted as a solution by mental health professionals, and the success or otherwise of each attempt made against that problem.

PIE Notes begin by outlining an individual’s background, documenting personal history, demographics, cultural background, strengths and challenges to inform the creation of a personalized treatment plan that resonates with their identity while supporting meaningful progress.

PIE Notes are composed of three main sections. The “Interaction” section tracks client relationships with mental health professionals and their interactions, helping track the effectiveness of interventions employed during therapy sessions and offering valuable insight into a client’s treatment journey. Finally, “Plan” details current goals and next steps in therapy plans outlined by each client; providing mental health professionals with a clear picture of a client’s progression, making PIE Notes an indispensable resource.

Mental health progression notes often follow a standard format, outlining sections for the client’s presenting issue, evaluation of that issue and proposed remedies. AI-powered medical scribes such as Quenza simplify this process by collecting key clinical details automatically while simultaneously enabling therapists to quickly create and sign progress notes via their secure HIPAA-compliant client portal; once signed off by both parties they’re automatically archived into each patient’s digital record for completeness and accuracy.

Focused DAR Notes

Nursing documentation requires nurses to adhere to certain standards, which includes using a consistent format for medical charts so that information can be understood by healthcare providers who may not have direct knowledge of a patient’s individual medical history.

At the outset of any document, it is essential to record both date and time to prevent errors in documentation of chart updates. Next, the objective data section should contain any observable and measurable information gleaned during your patient assessment such as vital signs or lab/diagnostic test results collected during assessment. Finally, action or response section could contain nursing interventions related to your objective data such as administering medications, reassessing patient’s condition or informing other healthcare professionals regarding findings.

If a patient was complaining of abdominal pain that interfered with her ability to breathe, then their nurse should note this in the objective data section of their F-DAR chart in order to alert other healthcare providers and allow them to devise an appropriate treatment plan to address the issue.

F-DAR charts are often included as part of a patient’s health record and serve to provide an easier, quicker and more complete way of documenting important patient details. Nurses often utilize an F-DAR template in order to save time and improve workflow efficiency.

F-DAR charts offer several benefits to healthcare providers who may not be versed in medical terminology, making the charts accessible and easily transferrable between paper documents and online platforms for care management purposes.

F-DAR notes provide many important advantages to nurses, helping them prioritize patient needs and enhance overall clinical outcomes. Furthermore, these documents can quickly be accessed by other healthcare providers – helping prevent miscommunication between departments – while simultaneously helping ensure that patient medical records accurately represent current state.

While there are several formats you can use to chart, this book this focus on SOAP Notes and PIE Notes.

SOAP Notes Charting for Nurses

SOAP Notes charting is an effective method of documenting patient interactions used by healthcare professionals. The notes often serve to share among multiple providers who work on helping the same individual address health concerns.

Nursing SOAP notes comprise four components: Subjective, Objective, Assessment and Plan. Subjective data refers to any information reported by a patient such as “my nipples hurt when nursing.” Objective data such as blood pressure measurements can also be collected as objective measurements.


SOAP Notes charting is an organized way of documenting patient encounters that includes four basic components – subjective, objective, assessment and plan – used by healthcare providers such as nurse practitioners to create easy-to-read patient notes.

SOAP notes contain two components, subjective and objective, to fully capture a patient’s visit with their physician or healthcare provider. Subjective components detail what the patient reports during their visit such as symptoms or feelings they are experiencing – it’s essential that these details be written down for future reference by healthcare providers in making diagnoses.

After writing the subjective section of a SOAP note, healthcare professionals will move onto creating its objective section. This document contains data that can be measured like blood pressure and weight; results of any tests conducted; as well as any information regarding any symptoms identified during assessment of patients by healthcare providers. Having this objective component helps physicians evaluate whether any serious medical problems exist with patients’ health status.

Once a healthcare professional has completed the objective section of a SOAP note, they will move onto the assessment portion. Here they will list any observations about patient’s behavior or physical examination that may help inform diagnosis based on symptoms exhibited. This assessment should also cover treatments tried by physicians with this patient.

SOAP notes charting is an efficient and effective method of documenting patient visits. Health care providers can use SOAP notes to establish a standard format for patient charts, and ensure that information is recorded accurately. SOAP notes are utilized by various professionals such as nurse practitioners, nurses, counselors and physicians; using them ensures you provide quality care that assists your patients’ recoveries from injuries or illnesses.


A nursing SOAP note is used to document patient encounters, typically created by nurses but often reviewed by physicians, nurse practitioners and other healthcare professionals. Therefore, its accuracy must be ensured while its interpretation should also be easy for all readers of the document.

Subjective data in a SOAP note refers to what the patient tells the nurse about their symptoms and concerns, such as their level of pain or location of symptoms. Subjective information can also include medical history, family history and allergies of their patient. Active listening by nurses is essential when collecting this type of subjective data for these notes.

SOAP notes include objective data collected during patient assessments by nurses. This may include vital signs, results of laboratory and diagnostic tests as well as observations made by the nurse during visits. It’s crucial that nurses accurately interpret and record objective information; in addition, their notes will likely be reviewed by other members of their healthcare team.

Nurses should take great care when charting to ensure that they use appropriate medical terminology and abbreviations, particularly SOAP documents which may be reviewed by other healthcare professionals who may misinterpret incorrect terminology used. This could result in inaccurate diagnoses for their patient. Furthermore, SOAP documents are frequently used for billing purposes so must clearly show evidence that services were rendered.

SOAP documents typically include a plan section that outlines the treatment that will be provided to a patient based on assessment and outcome sections of their note, such as prescription, lab orders, referrals or appointments. Nurses should regularly evaluate whether patients have achieved their goals or whether their plan needs to be changed in any way.


One of the primary objectives of SOAP is recording objective information about your patient. This includes things you can observe, hear or measure such as vital signs like their heart rate and blood pressure as well as diagnostic test results. A nurse should seek to record both subjective and objective information that contributes to diagnosis.

Subjective data in nursing SOAP notes is what the patient reports as their symptoms and experiences. This may include what the individual is feeling such as pain or numbness, their medical history and family history as well as any allergies they have. A nurse should actively listen to all forms of communication from both verbal and nonverbal channels from patients in order to find out why each symptom exists and assess each symptom thoroughly to pinpoint its source.

The nursing SOAP note format was developed to aid nurses in documenting assessments in an organized and concise manner. Unfortunately, however, many nurses make errors when writing these notes; whether new to nursing or experienced, avoiding common SOAP note mistakes will allow you to become more efficient in your nursing practice.

Whenever working with another professional, it is vital that they coordinate on their nursing SOAP assessment of each patient. This ensures that you both have accurate and up-to-date information regarding them; additionally, collaboration enables better patient outcomes and care delivery.

As part of your assessment, when reviewing the charts of patients you should search for any previous SOAP notes in their chart. Reviewing this information can give you valuable information, including what has been tried in the past and their responses to treatments; this can help determine the optimal approach for their care.

Always keep in mind that SOAP notes serve as documentation of patient encounters, not opinions or embellishments of your assessment. Your notes will likely be read by other health care providers who don’t possess your level of insight into a patient’s circumstances – keeping SOAP notes concise will enable these professionals to grasp all necessary details without needing to wade through unnecessary information.


Nursing personnel frequently rely on the SOAP note technique when documenting patient interactions. This methodology offers a framework for writing documentation of these encounters and includes four essential components: subjective, objective, assessment and plan. Each element carries with it different formatting and content requirements; all are designed to help nurses organize their thoughts and create accurate patient records.

The subjective section is the first component of a nursing SOAP note and contains all information gleaned from interactions with patients or family members, such as observations or statements made directly to nurse from them or by other members. Furthermore, this section can include past medical history information as well as current treatment options available to them.

Patients typically report multiple symptoms; however, one main complaint or chief concern (CC) should be recorded and noted in subjective data. It could be anything from specific symptoms, previous diagnoses or simply a statement outlining why the person has entered hospital care.

After collecting subjective data, nurses should conduct an assessment of a patient’s condition by combining subjective and objective information into an accurate diagnosis. Furthermore, this evaluation will allow for identification of appropriate interventions.

This portion of a SOAP note documents all of the information a nurse is gathering on behalf of the patient to develop an action plan for care, which may range from medication administration or education, as well as setting goals together and measuring progress toward those goals. Furthermore, any new or worsening symptoms should also be documented here.

Writing a nursing SOAP note takes time and care, as well as finding an uninterrupted place free from distractions in which to do it. Hospital environments may make this task challenging. To ensure no information is forgotten or missed, SOAP notes should be written as soon as the patient session concludes; otherwise contact your nursing supervisor immediately with this oversight.

PIE Notes – Streamlined Charting for Nurses

Nursing notes are a vital component of patient care. Nurses must note all they witness on a shift as well as any pertinent medical data relevant to each patient.

Documenting every visit properly is vital in order to prevent malpractice claims and safeguard nurses’ licenses, yet taking notes can be tricky when trying to balance medical terminology with observation.

PIE Notes are Short and Sweet

Documentation is an integral component of mental health treatment, helping ensure that individuals receiving care have their needs fulfilled and are making progress. Unfortunately, documentation can often become time consuming and tedious; thankfully there are methods for nursing charting that make the process faster and simpler – such as pie charts with three short sections for Problem (P), Intervention (I), and Evaluation (E).

PIE notes are an ideal method of documentation as they offer a clear and concise summary of a client session while including all pertinent details. Furthermore, PIE notes are easy to learn and can be utilized by both newcomers and experienced nurses; furthermore they can easily be integrated into existing care plans.

Pie charts have quickly become an indispensable tool among healthcare professionals as an alternative form of documentation for nursing records. They enable nurses to keep records in an easily navigable format while easily communicating between themselves – helping to make changes quickly without errors occurring, plus serving as an excellent visual tool that aids clinical decision-making and patient care.

Mental health professionals find the PIE note format especially beneficial, as it offers a comprehensive view of person-in-environment mental health treatment. Not only does this format document a client’s personal history, demographics and cultural influences – it also documents therapeutic interactions and interventions between themselves and clinicians.

Writing PIE notes properly can be an effective tool in supporting and advancing holistic mental health treatments, and providing effective communication among multiple mental health providers ensuring that individual’s needs are being fully met and care continues between sessions.

Writing effective PIE notes requires using person-centric language that acknowledges an individual’s autonomy and preferences, adhering to ethical and legal regulations for safeguarding client confidentiality, documenting all symptoms/behaviors that arise for clients as a whole, capturing each of their individual needs.

They’re Easy to Learn

Nursing students need to master many essential tasks, and taking notes is one of the most essential. This process includes balancing medical terminology with writing skills and observation in order to form an accurate portrait of patient health status. Accuracy of nursing notes allows team members and patients alike to easily comprehend all information provided.

Documentation in mental health care is vital, aiding billing, tracking progress and formulating treatment plans. Clinicians frequently prefer following a particular format for documentation – PIE Notes is one such approach which offers an easy-to-learn structure designed to focus on problem-focused solutions. PIE notes consist of three short sections which include information such as the client’s presenting problem, therapeutic interventions utilized and any reactions the intervention had on them as well as responses by clients themselves to them.

Effective mental health documentation is crucial to providing high-quality care, with PIE notes documenting each client’s personal history such as demographics, cultural influences, strengths and challenges – this helps other mental health professionals have a fuller understanding of who the individual is as well as guide their treatment strategies.

PIE notes’ Interaction section documents the client-psychotherapist relationship. This section may include observations, reflections, and any therapeutic interventions used during therapy sessions that were beneficial in tracking progress over time and identifying future areas of focus.

PIE notes’ Environment section examines how environmental influences impact mental health of their client and can include family, friends, school, work, and community factors that may have an effect on mental wellbeing. Documenting such details in PIE notes will inform future treatment interventions as well as improve resilience and well-being even under difficult conditions. Furthermore, recovery-oriented care practices which promote autonomy and empowerment among their client base is enhanced through this element; so mental health professionals must document these impacts accurately for comprehensive and holistic care provision.

They’re Problem-Focused

An approach to nursing charting that prioritizes problem documentation gives nurses more focus and makes finding specific information more straightforward, according to Hudson. A nurse may use different techniques for documenting problems; what’s key, according to Hudson, is documenting both their existence and any steps taken in response.

One popular technique is PIE Notes, an acronym of “problem, intervention and evaluation.” Nurses using this system record assessments on daily flow sheets before writing progress notes that focus on problems rather than medical concerns – an adaptation of POMR used initially by physicians but since adopted by nurses.

PIE structure calls for each problem to be documented on a separate form or flow sheet and assigned a number, so nurses can refer back to it when writing progress notes. Nurses must document each action or nursing intervention taken and assess its success or otherwise.

Focusing on patient concerns instead of issues can help nurses write progress notes without negative connotations associated with traditional problem-focused charting, according to Hudson. Furthermore, she says it can make progress notes more intuitive for nurses and may prevent them from becoming bogged down with medical terminology – an attractive alternative to SOAP(IER), which was once widely employed but now faces declining usage within healthcare environments.

Head-to-toe format nursing notes organize their notes according to body systems, observations and interventions – this helps avoid duplication of work while ensuring all shifts document similar information, says she. Furthermore, narrative notes take longer and are difficult to read by other nurses.

Another nursing documentation strategy involves charting by exception, which takes less time to complete as it only records events that deviate from normal or expected behavior. Unfortunately, however, tracking trends or changes over time is more challenging with this method; small mistakes in charts could even cause legal trouble so nurses must always double-check all their work before turning it in.

They’re Easy to Share

Nursing requires documenting patient conditions throughout their stay in medical facilities. The information gleaned can then be utilized by a team of nurses in providing optimal care, however writing an effective note for nursing staff to use may prove challenging as it often contains abbreviations and medical jargon that only other professionals understand.

Nursing pie charts can help tackle this challenge by making all of the information contained within a nurse’s notes more easily understood by any other members of medical staff who need to read them, as well as sharing and reviewing it remotely with teams.

The pie chart is a visual representation of data that helps communicate proportions. Similar to circle graphs, but with greater data intensity ratios. It can even be used to display multiple statistics in one chart – or expanded out further for greater effect! It may even be broken apart to highlight specific sectors or percentages for outcomes.

Mental health professionals typically utilize a specific format when documenting psychotherapy sessions. This ensures that all sessions are appropriately documented – something required by insurance companies. PIE note format is one such popular choice used by mental health professionals for this purpose; other formats include SOAP, DAP and GIRP.

PIE notes, as their name implies, are a type of note which involves three principal components: Person, Interaction and Environment. The Person section details a client’s personal history – such as their cultural background or strengths – helping create a holistic approach to mental health care.

The Interaction section evaluates the therapeutic relationship between client and mental health professional. It includes documentation of interactions, observations, and reflections related to therapy; this data allows mental health professionals to identify gaps in treatment plans as well as monitor progress and measure effectiveness of interventions. Finally, Environment component evaluates external influences that influence psychological functioning; these may include social, familial, or cultural factors.

Electronic Health Records for Nurses

EHRs provide nurses with instantaneous access to patients’ medical histories, while also helping prevent medication errors caused by legible handwriting that often is the source of confusion.

Nurses require accurate documentation formats in order to facilitate patient care, improve clinical outcomes and foster interprofessional collaboration. To maximize its benefits, follow the nursing process for electronic health records documentation.

Patient Access

NPs serve as the frontline in managing patients’ health. Therefore, they must effectively communicate with patients and understand the intricacies of their medical conditions; this is particularly essential when treating complex or rare illnesses that require multiple specialists and physicians for diagnosis and care. Electronic Health Records can be utilized to share a complete picture of a patient’s medical history thereby saving time and increasing efficiency across both nurses and physicians.

Electronic health records have completely transformed healthcare practice. Now physicians and nurses can access test results, prescription orders, referrals and more from anywhere with internet access – improving communication while eliminating duplicate testing. Furthermore, numerous tools have been added to streamline document management such as integrated scheduling systems that link appointments with progress notes; automated coding/claims management capabilities; as well as shortcuts that expedite data entry processes.

Nurses can utilize EHR systems to track medication dosage and administration times and reduce medication errors – one of the leading sources of healthcare errors. Some EHR systems even integrate bar code scanning technology which alerts nurses if medication containers have been moved from their proper locations, potentially saving lives by alerting nurses when containers have been compromised or removed altogether.

EHRs also help ensure patients receive the appropriate care. Medication known to interact with certain drugs can be highlighted so nurses know not to administer them; thus reducing adverse drug events, which could prove deadly for some patients.

Use of an EHR may increase nursing satisfaction. A 2022 study reported that 69% of nurses found their EHR either useful or very helpful; yet some nurses have voiced concerns over the time and effort spent updating these databases, as it forces them to break eye contact to enter data; this can be mitigated through using dictation software or mobile devices that allow nurses to stay engaged while entering data.

Medication Reminders

Medication errors can happen at any stage in the medication process – from physician order through physician transcription, pharmacy processing and distribution, nurse administration and nurse dispensation. While mistakes committed at earlier points in the process may be detected during review by clinical staff during review sessions, those made at bedside typically go undetected. An electronic health record (EHR) can help reduce medication errors by prompting nurses to administer drugs at specific times, avoiding drug interactions and displaying critical lab values for easier documentation.

An eMAR system can also increase efficiency for nurses by scanning unit dose barcode labels and matching them against medication records. Once these are matched up, software alerts the nurse if any medicine they plan to give out is either not authorized, expired, or incompatible with treatments already taken by patients.

EHRs offer more than just documentation benefits; they also enhance communication and collaboration among facility staff members. With its powerful features, clinicians can share patient-specific comments, alerts and questions easily across clinics without dealing with handwriting that’s hard to read or communication lag time issues. In addition, EHRs can integrate with external immunization registries or information systems so clinicians are aware of patient vaccination statuses as well as potential complications that might arise as a result.

An EHR can assist physicians in reducing medical errors and avoiding drug interactions by alerting users about food/drug interactions, allergies and patient-specific conditions. Facilities may also find it easier to monitor vaccination status and adhere to treatment plans with this technology, by interfacing with external immunization registries, information systems and public health agencies. EHRs also play an invaluable role in clinical decision-making by making data and metrics more intuitive, as well as eliminating paper forms which often cause frustration among staff and increase risk of error. With no need for paper forms anymore, EHRs reduce printing and filing costs significantly, saving facilities money while simultaneously decreasing their carbon footprint.


Interoperability makes healthcare professionals’ jobs easier by providing access to this data directly, rather than manually moving it between platforms – saving both time and effort while decreasing errors caused by duplicate testing or data entry. Nurses must have access to accurate and up-to-date information in order to make informed decisions for their patients’ treatment.

According to a study at a tertiary medical center, nurses reported that EHR implementation increased their satisfaction with nursing profession. Nurses stated this by being better able to monitor patient progress and reduce overall workload with improved accuracy for nursing documentation and medication information; and being able to collaborate better with co-workers as well as improve patient safety.

Nursing documentation is a critical element of EHR systems, yet can also be an arduous task. A 2020 survey conducted by Cleveland Clinic reported that nurses spent an average of 123 minutes per shift navigating their EHRs actively – this burden must be reduced as part of value-based care requirements and regulatory obligations; healthcare entities must find ways to ease clinician documentation pressure.

One way of accomplishing this goal is by investing in an EMR platform that supports HL7 integration services, so data collected and entered meets industry standards and can be easily accessible by other platforms. Additionally, investing in such an EMR can aid ML and analytics initiatives by creating a standard set of data which can be used for modeling.

One way to improve nurses’ EHR experience is through providing training on how to navigate and utilize its features effectively, whether that means webinars or on-site classes. Training provides newcomers as well as established ones a better grasp of the platform while offering tips on maximizing its functionality.

Healthcare providers should make sure their EHR system offers customer support via a phone number, email address, website and/or customer forum. This is particularly essential given that healthcare is constantly changing; thus adapting an EMR to evolving practice models and new payment protocols must be ensured by its EMR solution.

Patient Safety

Since 1999’s Institute of Medicine report “To Err is Human,” it has become generally acknowledged that errors in hospital care are more often the result of systemic issues rather than individual mistakes. Such issues could include poor communication among healthcare staff and inadequate procedures for reporting medical mistakes or safety concerns – issues in which nurses play an integral part in developing solutions which foster positive patient outcomes.

No matter their best efforts in providing high quality care, mistakes may still happen. They range from minor to serious occurrences such as prescribing incorrect medications or misreading handwriting; sometimes fatal injuries result from such errors. To prevent errors from recurring, nurses must implement clear documentation guidelines and reporting processes in place.

EHRs provide numerous advantages in this area. EHRs can reduce documentation burden by enabling nurses to enter data once and have it populate multiple records automatically – saving both time and ensuring consistent record entry. In addition, EHRs can alert nurses of potentially hazardous interactions between medications as well as prevent duplicate tests that would incur unnecessary costs.

However, various factors can impede the accuracy and effectiveness of an EHR. Erroneous information may result from human errors, software malfunctions or the design itself – for example if shortcut buttons are frequently clicked repeatedly by elderly or underweight patients it can override medication orders, leading to toxic doses; additionally frequent or irrelevant warnings generated by EHRs can interrupt work flow and frustrate users.

To prevent these problems, the nursing profession must ensure its computerized systems are current and that all staff have received appropriate training. Furthermore, hospitals should foster an environment of patient safety by making clear to all staff that each plays an integral part in maintaining it; any staff members that feel concerned should express this at once.

Narrative Charting for Nurses

Narrative Charting is a form of documentation used by nurses. Similar to running logs, Narrative Charting records everything that happened during shift and serves as evidence in any medical malpractice claims or lawsuits.

Nurses must document information accurately and comprehensively to protect themselves in case something could become significant in the future. It’s vitally important that any data that could prove essential isn’t missed out when creating documentation for future reference.

What is a Narrative Note?

Nurses typically spend more one-on-one time with patients than doctors do, enabling them to more readily detect subtle changes in patient conditions and responses to treatment. Their observations must be documented via nursing notes as an essential component of effective clinical care; and nurses using narrative nursing notes must use a certain writing style known as narrative nursing notes when documenting these observations.

Narrative nursing notes are documents that outline details about a patient’s health status, nursing interventions and evaluations provided to treat that condition, and patient response to treatment. Usually written in paragraph form, narrative nursing notes tell an engaging tale about health statuses of individuals receiving care to improve them.

Narrative charts are a form of nursing documentation often combined with flow sheets and graphs, offering nurses an additional way to describe a patient’s health status more fully than through other types of documentation such as flow sheets or graphs. Their main advantage lies in providing more granular details about patient health status than can be provided via flow sheets and graphs.

Although there are guidelines nurses should abide by when writing quality narrative nurse’s notes, each nurse will have her own individual approach to communicating and documenting. When creating such notes it’s crucial that both objective and subjective data is included such as heart rate, blood pressure and temperature measurements as well as any feedback provided from either the patient themselves or his family including emotional state assessments and medication response information.

Narrative nurse’s notes can make healthcare professionals’ jobs easier by familiarizing them with its writing style and standardizing information across a facility or organization. This can especially come in handy when providing referrals or evaluations from doctors or hospitals outside their practice; so using standard documentation helps boost credibility while making it simpler to provide patient information to those that need it.

How Do I Write a Narrative Note?

Narrative nurse notes should be written as soon as possible following an assessment or administration. Delaying writing the note increases the risk that something will be overlooked or misinterpreted and leaves medical professionals wondering whether their actions have actually been accomplished as described.

Nursing narratives aim to provide readers with a thorough and clear description of a patient’s condition and response to treatment, as well as objective data (measurable/observable measurements such as height/weight measurements or lab test results) and subjective information that is more difficult to measure (such as feelings/perceptions of the patient). By creating this comprehensive picture of each individual patient it enables healthcare providers to accurately diagnose issues and prescribe the most suitable therapy options.

Nursing narratives must be written in paragraph form and signed. Keep in mind that other healthcare providers will read your notes, so the language should be professional and suitable for an academic setting. Avoid emoticons and abbreviations use, and use proper grammar and spelling when writing your notes.

Writing a narrative may be daunting for new nurses. With practice and familiarity comes ease. A nursing narrative typically includes three sections: background information about patient history and symptoms; assessment which includes nursing diagnosis as well as detailed description of current state; recommendation or suggestion based on assessment which should include future care plan recommendations or plans; recommendation or suggestion which summarizes all this data gathered through previous steps – usually structured around three main pillars such as background, assessment, recommendation or suggestion and next steps or considerations.

At the conclusion of any narrative report, it is necessary to record the outcome of patient treatment as well as any changes caused by nurse actions. At this point, a document should be signed and dated, while also giving a copy to the patient.

What Elements Should Be Included in a Narrative Note?

Writing narrative nursing notes requires taking an objective view of their patient. While reporting subjective details such as feelings is permitted, only objective data must be included to enable other healthcare providers to come to evidence-based medical conclusions about health status and treatment plans for each patient.

Nursing narratives must include dates and times so the nurse can refer back to this document when reviewing progress or treatment of patients. Next comes a short summary of current condition for each patient as well as secondary issues experienced such as symptoms such as coughs or headaches that have arisen as a result. Finally, nursing narratives should include any actions the nurse has taken – such as prescribing medications to patients or administering tests – at this point in time.

Once all this information has been compiled, a nurse should conclude her narrative by listing likely diagnoses and results of assessments she conducted. Nurses must take great care when writing these details as it will be utilized during future patient care. Once complete, check over and ensure all relevant details have been included before filing securely onto a HIPAA-compliant platform.

Nurses must ensure they submit timely nursing notes. Delays between writing documentation of an event and its actual occurrence may lead to miscommunication and lack of clarity among healthcare professionals. Nurses should avoid abbreviations use without first receiving training from their healthcare facility – otherwise this could confuse other healthcare workers as well as potentially cause inaccurate data entry into patients’ records.

Nurses must remember that family members of patients may read narrative notes, so it is important for them to avoid using inappropriate language and revealing personal opinions in these notes. Nursing notes must always remain professional and factual regardless of who may or may not be present during examinations.

How Do I Finish a Narrative Note?

Nurses should complete a narrative note by including both objective and subjective data when conducting their evaluation of patients, with objective data such as vital signs or lab results being documented in accordance with standard formats used by facilities, while subjective data may include feelings, perceptions and concerns expressed by their patient(s). This helps medical professionals communicate more efficiently while decreasing miscommunication that could lead to medical errors.

Nurse notes should ideally be written immediately after each patient encounter takes place to reduce any potential changes in condition between writing the report and when other medical professionals review it. Furthermore, adding anything new into a narrative note that is already documented on a flowsheet or another set of notes could create confusion and open your facility up to liability claims.

Story in a nurse’s chart must include a clear beginning, middle, and end with some form of rising action and climax. There should also be an identified problem or challenge which the protagonist must overcome; and an outstanding narrative essay will reveal a writer’s creativity by exploring multiple viewpoints of an event or situation.

Finalizing a narrative requires adding an appealing yet realistic setting that readers can interpret as part of the tale. For instance, this might involve placing events within an established time period or environment known to readers. Furthermore, there should also be elements relevant to the subject matter or topic of an essay that contribute to this setting.

Narrative charting can be an effective tool for nurses in documenting patient care and providing complete health status snapshots for other medical professionals to read. When using narrative charting as part of medical documentation, remember its purpose – that of providing complete health status pictures in a succinct and easily readable manner.

The Essential Components of Effective Documentation for Nurses

Documentation is an integral component of nursing that ensures continuity of care, clinical reimbursement and avoids malpractice. Furthermore, nursing documentation helps nurses communicate effectively with colleagues and other healthcare providers; for optimal performance it should be clear, concise, legible/readable and complete.

Studies have revealed that nurses devote most of their time to documentation. Some researches focus on general recordkeeping practices while others dive deeper into specific components.

Patient-centered care

Patient-centric care is an approach to healthcare that emphasizes meeting patient needs, values and preferences in addition to building collaborative relationships between healthcare professionals and patients. It takes into account their mental and physical well-being while taking into account lifestyle, cultural traditions, values that may impact healthcare goals as well as social and economic status of each individual patient.

Patient-centric care not only brings immense advantages to patients but can have a positive effect on a hospital’s bottom line as well. By eliminating unnecessary procedures and improving patient satisfaction, this method of healthcare increases efficiency by building trust between nurses and their patients while simultaneously increasing efficiency across healthcare organizations.

Patient-centric care is traditionally provided by healthcare professionals through direct interactions with their patients, which could include consultations or meetings with family and friends of the patient as well as various health education tools, such as self-management techniques or coping skills training. Nurses should pay particular attention during these conversations in taking note of each individual patient’s goals as they relate to treatment plans; documenting all this data so there can be a clear record of progress being made on behalf of these patients.

Step one in providing patient-centric care is to identify healthcare problems for each individual patient, which will allow nurses to determine what steps need to be taken next. Nursing documentation must be succinct and accurate, recording date/time of each interaction as well as results or any changes to plans of action taken by both nurses and doctors.

Nurses must not only document healthcare problems for each individual patient but must also attend to emotional needs as part of patient-centric care. In the past, nurses did not pay enough attention to emotional aspects of patients’ lives – however this must change as part of providing quality healthcare.

Patient-centric practices require several changes to current methods of medical practice, including shifting how success is measured and providing clinicians with communication strategies training. Unfortunately, however, such changes can be hard to implement with an ever-busy physician workforce and limited reimbursement systems.

Patient education

Patient education is an integral component of nursing practice. It helps patients understand their disease and treatment, encouraging participation in their care. Studies show that informed patients tend to make healthier lifestyle choices and adhere more faithfully to medication or health care regimens, leading to fewer health-related complications while being less strainful on limited healthcare resources.

Documenting in nursing is a complex and time-consuming task, requiring careful observation of symptoms, activities, interactions with patients and interactions between healthcare providers. Documentation must meet professional nursing practice standards or else inaccurate and incomplete records could result. Any changes in condition or plan of care must also be documented accurately with all pertinent details documented such as date and time of visit able to be accessed by healthcare professionals in an easily searchable format.

Nursing documentation is vitally important to patient safety, providing a record of care. Furthermore, nursing documents may assist in medical negligence litigation proceedings; however, nurses should keep in mind that nursing documents do not replace clinical judgement; if she feels uncertain that her documentation is complete or accurate she should seek additional clarification before continuing with the assignment.

Studies examining nurses’ recordkeeping practices and documenting their effects from different changes have spanned various settings, interventions applied and methodologies utilized. Although results of such studies vary greatly between settings examined, interventions applied or methodologies employed, evidence does suggest that well-constructed documentation systems can lead to improved documentation as well as patient outcomes.

Hardey and colleagues31 conducted a qualitative study that observed nurses at five acute elderly care wards. They discovered that when making decisions regarding patients’ care, nurses often relied on informal sources like Kardexes or personal notes for information when making decisions – often viewing documentation as tedious and time consuming; Hardey refers to these informal sources of data as scraps – which formed dynamic information systems according to shift work patterns.

Documentation standards

Documentation standards provide guidelines that nurses must abide by to ensure accurate patient records are kept. This is essential in protecting both patients and nurses in case of medical errors; additionally it allows nurses to have an accurate record of everything they have done during shifts; plus hospitals use documentation standards as a way of tracking what went wrong during shifts and making improvements where necessary.

Nursing documentation, whether on paper or electronically health records (EHRs), should be clear and consistent for easy understanding by patients, healthcare team members, doctors, as well as clinicians themselves. Furthermore, it should be easily accessible and update-able for future reference.

Avoid vague or ambiguous statements which can confuse readers. For example, nurses should avoid writing that a patient’s bed is wet when in fact it could contain “a large amount”. Documentation should always be objective and accurate – nurses should avoid recording subjective opinions in their charts without using quotation marks to attribute the comments back to the proper person.

Good nursing documentation is indispensable for many reasons, including determining clinical reimbursement, avoiding malpractice lawsuits, facilitating communication among nurses across facilities and disciplines and mitigating liability risks both individually and collectively for healthcare providers and employers.

Although accurate documentation is an integral component of effective patient care, many nurses lack the skills to write effective patient records. This poses a problem as improper documentation can lead to poor patient outcomes and malpractice suits as well as creating barriers to patient care. Therefore, nurses need to learn accurate documentation in order to provide superior care while further developing themselves professionally. Lonnie Brass of MAS Medical Staffing Travel CNA lives and works in Joliet Illinois as a medical staffing professional; in his free time he enjoys reading fantasy novels, watching Marvel movies, coffee grizzlies bears as well as traveling.

Computerized documentation

Documentation is an integral component of nursing, yet can sometimes seem time consuming and cumbersome. But taking the time to properly document will make your work as an RN easier and will allow for clearer communication among nurses as well as patients.

Documenting patient care and healthcare provision is vitally important to maintaining continuity, determining reimbursement rates, avoiding malpractice, and protecting nurses from being blamed for anything they didn’t say or do; plus it will allow them to demonstrate whether medical errors did or did not happen. Document every step from recording fridge temperatures to administering medicines to protect from possible accusations against nurses who weren’t at fault and prevent malpractice lawsuits from being brought forward against them.

Computerized documentation offers many hospitals greater convenience and security while saving space by reducing the amount of files in nurses’ filing cabinets. The system will automatically update charts without needing to store paper documents that may get misplaced or stolen; reading computerized documentation also reduces misinterpretations risk significantly.

Computerized documentation offers another advantage of identification: it reveals who has accessed and edited documents after they have been authenticated, helping nurses track which notes have been changed after authentication has taken place. This helps prevent unauthorized access and fraud by employees who should not have access to records as well as detect manipulation by nurses of documents that should not have been altered.

Computerized documentation not only facilitates communication between nurses and patients, but can also contribute to overall organizational health. For instance, software can identify patterns within data that suggest areas for improvement – helping managers make more informed decisions regarding quality of service provision and staffing requirements.

Crafting an effective nursing document is a complex task, which demands high levels of critical thinking. Therefore, nurses should use best practices in their documentation in order to create effective documents which are easy for patients to comprehend and provide high-quality healthcare to them.

About the Author:
Mark Aquino is a registered nurse in California with a Bachelors of Science in Nursing and Masters of Health Administration from West Coast University. He has at least 5 years of experience in the front lines as a visiting nurse in home health and hospice in direct patient care. He is author of OASIS NINJA: A Home Health Nurse’s Guide to Visits, Documentation, and Positive Patient Outcomes. This guide provides nurses with the information they need to provide quality care to their patients in the comfort of their own homes. He also writes books about how to live a good life and how to improve yourself on a daily basis such as Self Help Transformation: An Evidence-Based Approach to Personal Transformation for Mental Health, Physical Fitness, Relationships, and Career. You can also find all his books here. Learn more at

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