Documentation Video Resources

For Nursing Home Care Facilities

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The Importance of Documentation – Introduction

In order to work as a care team to deliver high quality care, accurate and thorough documentation is a necessity. The entire team relies on documentation to provide a clear picture of each resident in the facility. As a care provider, you know the residents best and your role in complete documentation is crucial.

3 Takeaways for NH Staff:

  • Documentation gives a clear and complete picture of the resident’s status.
  • The healthcare team relies on documentation to provide complete and consistent resident care.
  • Incomplete documentation can cause mismanaged care of a resident.

Establishing “Normal”

It is important to understand a resident’s “normal” during: their habits and patterns, interaction with others, and their vitals and physical assessment. Recognizing when a resident is not at their best during the above instances will alert staff that a change has occurred.

3 Takeaways for NH Staff:

  • Documenting a baseline is essential to detect changes in condition.
  • Make sure to document resident routines like schedules and meal intake.
  • If you don’t know a resident’s “normal” – ask someone!

Noting Relevant Changes

Some changes in the resident are obvious, but others can be small. The little changes in a resident’s baseline can be the key to understanding why a resident’s condition is changing and should be documented.

3 Takeaways for NH Staff:

  • Small changes matter – think about vitals, physical assessments, habits, etc.
  • Document ALL changes – this gives other providers a clear resident picture.
  • Relevant changes can add up to bigger warning signs that the resident needs more attention.

Completeness

Residents rely on everyone having a complete and accurate picture of their situation.

3 Takeaways for NH Staff:

  • Include all details of a situation in your documentation.
  • Document so that someone else can take the next steps in resident care.
  • Missing information can lead other staff to form an inaccurate picture of the resident situation.

Timeliness

Decisions in resident care are based on daily documentation, if there are any delays in documentation, the resident picture may have missing pieces and lead to inaccuracies in care.

3 Takeaways for NH Staff:

  • Document ASAP – Late entries can be too late to be helpful if something is changing with a resident!
  • Real time documentation is fresh in your mind and more accurate.
  • If you are unable to document everything in real time, prioritize changes in condition, new orders, testing results, and changes in resident baselines.

Key Events

Every milestone or event in the day of the resident contributes to the picture and when these key events are not documented in the EMR, care providers can miss out on the full context of what might be going on with the resident.

3 Takeaways for NH Staff:

  • Context is everything – missing details can confuse the clinical picture.
  • Make note of appointments, procedures, bad or upsetting news, and other events.
  • Identify key events so that other care team members can identify when a change started.

Sharing the Story

Sharing the story the right way guarantees the rest of the team reviewing the documentation receives your perspective and knowledge of what’s going on with the residents.

3 Takeaways for NH Staff:

  • A complete story allows the rest of the care team to make informed decisions.
  • Document things in order and share in a way that others can understand the series of events.
  • Your information is crucial to move clinical plans forward.

References:

Broderick MC, Coffey A. Person-centered care in nursing documentation. Int J Older People Nurs. 2013 Dec;8(4):309-18. doi: 10.1111/opn.12012. Epub 2012 Dec 7. PMID: 23216647.

Tuinman A, de Greef MHG, Krijnen WP, Paans W, Roodbol PF. Accuracy of documentation in the nursing care plan in long-term institutional care. Geriatr Nurs. 2017 Nov-Dec;38(6):578-583. doi: 10.1016/j.gerinurse.2017.04.007. Epub 2017 May 25. PMID: 28552204.

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