Concise
Concise as defined by google means “giving a lot of information clearly and in a few words.” It also means “brief; but comprehensive.”
In nursing you want to be straight to the point with your documentation, but be sure everything is understandable. The case scenario below has a lot of information. Chart the information as concisely as you can, making sure to leave nothing out.
Situation:
Mr. James is a 57 year old gentleman admitted to room 224A two days ago for dehydration secondary to nausea and vomiting for three days. His sclera is slightly yellowed and his abdomen is distended and tender to palpation, especially in the upper right quadrant. After two days of IV Lasix therapy, he has 2+ edema in his lower extremities to the mid-calf. (At admission he had 4+ edema up to the knee.) He complains of mild shortness of breath with moderate activity which he has experienced for several weeks. He has a history of alcohol abuse for 20 years, but denies any use in the past 6 months. He has no history of hepatitis or HIV. No history of drug abuse. At 7:45 AM, Mr. James is complaining of increasing nausea. He has had no emesis for at least 5 hours, but feels (and fears) the need to vomit is becoming imminent. His last dose of anti-emetic (Tigan) was given at 4:30 AM and he states, "It only slightly relieved the nausea this time." It let him sleep for about two hours, but now he's "wide awake and very uncomfortable." The orders for the Tigan are 200 milligrams (2ml) IM QID (four times a day), and is scheduled every six hours. It has only been a little over three hours since the last dose and is not due again until 10:30 AM. You tell him you will have to contact the MD for orders for something else. Mr. James is reluctant to have you do this. He thinks that if he can wait about 30 minutes, the MD is likely to be making his morning rounds. Mr. James wants to try to wait. He thinks he "can control the urge to vomit more it if he can get more comfortable in the bed." A quick assessment of vital signs and his body systems reveals no change in condition. In assessing Mr. James, you determine that measures, which usually help him to reduce his nausea, include using a cold cloth on his forehead and one on the back of his neck. He is usually more comfortable lying on his left side, but is on his right side now because he's trying to comply with the need to alternate the pressure on his skin. It has been about an hour that he's been on his right side. Turning can increase his nausea, but doing so slowly may be OK. You assist him to slowly turn and find a more comfortable position. You place the cold cloths on his forehead and the back of his neck, and he reports feeling "much better already." Slow deep breaths also help him to relax, as well as minimizing distractions such as the TV, lights and closing the door to the room. Pulling the curtains around his bed further isolate him and allow him to relax and concentrate on his slow breathing. In a few minutes, he is sleeping. How do you document your assessment and intervention?
Case Study from: NT Contributor; www.nursetogether.com/learning-nursing-documentation; “Learning Nursing Documentation” 2 Oct 2012; Web; accessed 7 Nov 2014.
What Not to Do, Tips on Charting Concisely: Patients will often tell you their entire health history when you are doing your assessments. It is up to you to decide what is pertinent and needs to be included in the documentation.
What to Do: Patient lying in bed on right side. C/O increased nausea, no emesis x5 hrs, next anti-emetic due @10:30. Discussed calling MD about nausea, pt wants to wait till MD makes morning rounds. Comfort measures provide. Abdomen is distended and tender to palpation. 2+ edema to BLE. C/O SOB with moderate exertion.
This charting has included all pertinent assessment details related to this situation.
Complete Charting
Complete- In your nursing documentation you want to be sure everything is included, even the smallest complaint or detail.
Situation:
It is close to the end of your shift, and you are receiving an ER admit. The patient is admitted for increased heart rate. The patient is bed bound and considered a total care patient. You do a quick head to toe assessment and notice there is a red, non blanchable area on her coccyx. During your charting the next shift is beginning to show up for report, so you leave the “red area” out thinking it is only red, and a small area and it will be gone in a few days. You give report and head out until next week. You return the next week and receive the same patient, only to find out that “small red spot” has now advanced to a Stage 2 pressure ulcer, and it was wasn’t caught until a few days after her admission. The supervisor goes back to your admission charting to see if anything about a pressure ulcer was charted, because if it was present on admission the hospital will recieve reimbursement for treatment. However, she sees the ulcer was not charted on admission, so it appears as if she got the pressure ulcer while here. The hospital must still treat it, but all costs come out of pocket for the hospital. How could you have charted to show the beginning ulcer was present on admission? Every detail counts, no matter how small!
What Not to do, Tips on Charting Completely: Do not omit any assessment details, no matter how small. Leaving out the skin assessment is saying you did not perform it.
What to do: Include the skin assessment. Non-blanchable red area to coccyx. (Be sure to chart everything no matter how small.
Concise as defined by google means “giving a lot of information clearly and in a few words.” It also means “brief; but comprehensive.”
In nursing you want to be straight to the point with your documentation, but be sure everything is understandable. The case scenario below has a lot of information. Chart the information as concisely as you can, making sure to leave nothing out.
Situation:
Mr. James is a 57 year old gentleman admitted to room 224A two days ago for dehydration secondary to nausea and vomiting for three days. His sclera is slightly yellowed and his abdomen is distended and tender to palpation, especially in the upper right quadrant. After two days of IV Lasix therapy, he has 2+ edema in his lower extremities to the mid-calf. (At admission he had 4+ edema up to the knee.) He complains of mild shortness of breath with moderate activity which he has experienced for several weeks. He has a history of alcohol abuse for 20 years, but denies any use in the past 6 months. He has no history of hepatitis or HIV. No history of drug abuse. At 7:45 AM, Mr. James is complaining of increasing nausea. He has had no emesis for at least 5 hours, but feels (and fears) the need to vomit is becoming imminent. His last dose of anti-emetic (Tigan) was given at 4:30 AM and he states, "It only slightly relieved the nausea this time." It let him sleep for about two hours, but now he's "wide awake and very uncomfortable." The orders for the Tigan are 200 milligrams (2ml) IM QID (four times a day), and is scheduled every six hours. It has only been a little over three hours since the last dose and is not due again until 10:30 AM. You tell him you will have to contact the MD for orders for something else. Mr. James is reluctant to have you do this. He thinks that if he can wait about 30 minutes, the MD is likely to be making his morning rounds. Mr. James wants to try to wait. He thinks he "can control the urge to vomit more it if he can get more comfortable in the bed." A quick assessment of vital signs and his body systems reveals no change in condition. In assessing Mr. James, you determine that measures, which usually help him to reduce his nausea, include using a cold cloth on his forehead and one on the back of his neck. He is usually more comfortable lying on his left side, but is on his right side now because he's trying to comply with the need to alternate the pressure on his skin. It has been about an hour that he's been on his right side. Turning can increase his nausea, but doing so slowly may be OK. You assist him to slowly turn and find a more comfortable position. You place the cold cloths on his forehead and the back of his neck, and he reports feeling "much better already." Slow deep breaths also help him to relax, as well as minimizing distractions such as the TV, lights and closing the door to the room. Pulling the curtains around his bed further isolate him and allow him to relax and concentrate on his slow breathing. In a few minutes, he is sleeping. How do you document your assessment and intervention?
Case Study from: NT Contributor; www.nursetogether.com/learning-nursing-documentation; “Learning Nursing Documentation” 2 Oct 2012; Web; accessed 7 Nov 2014.
What Not to Do, Tips on Charting Concisely: Patients will often tell you their entire health history when you are doing your assessments. It is up to you to decide what is pertinent and needs to be included in the documentation.
- Do not chart like you are writing a novel.
- Chart only pertinent information.
- Be concise and chart only whats happening at that time. Do not repeat things that happened days earlier and has already been charted.
What to Do: Patient lying in bed on right side. C/O increased nausea, no emesis x5 hrs, next anti-emetic due @10:30. Discussed calling MD about nausea, pt wants to wait till MD makes morning rounds. Comfort measures provide. Abdomen is distended and tender to palpation. 2+ edema to BLE. C/O SOB with moderate exertion.
- C/O means complains of.
- BLE means bilateral lower extremities, or both legs.
- SOB means shortness of breath.
This charting has included all pertinent assessment details related to this situation.
Complete Charting
Complete- In your nursing documentation you want to be sure everything is included, even the smallest complaint or detail.
Situation:
It is close to the end of your shift, and you are receiving an ER admit. The patient is admitted for increased heart rate. The patient is bed bound and considered a total care patient. You do a quick head to toe assessment and notice there is a red, non blanchable area on her coccyx. During your charting the next shift is beginning to show up for report, so you leave the “red area” out thinking it is only red, and a small area and it will be gone in a few days. You give report and head out until next week. You return the next week and receive the same patient, only to find out that “small red spot” has now advanced to a Stage 2 pressure ulcer, and it was wasn’t caught until a few days after her admission. The supervisor goes back to your admission charting to see if anything about a pressure ulcer was charted, because if it was present on admission the hospital will recieve reimbursement for treatment. However, she sees the ulcer was not charted on admission, so it appears as if she got the pressure ulcer while here. The hospital must still treat it, but all costs come out of pocket for the hospital. How could you have charted to show the beginning ulcer was present on admission? Every detail counts, no matter how small!
What Not to do, Tips on Charting Completely: Do not omit any assessment details, no matter how small. Leaving out the skin assessment is saying you did not perform it.
- Include all parts of assessment to prove you did it.
- Remember if not charted you didn't do it.
What to do: Include the skin assessment. Non-blanchable red area to coccyx. (Be sure to chart everything no matter how small.
- Non-blanchable means the area stays red when pressed on instead of turning white then back to red. This means the area is a Stage I pressure ulcer.
Picture from: Pregerson, Brady; http://scrubsmag.com/how-to-choose-the-right-words-when-charting/; “How to choose the right words when charting” 11 Jan 2010; Web; accessed 13 Nov 2014.