I have talked before about the importance of developing good documentation practice. But what exactly should we be documenting and how can we develop some sort of structured scaffolding to support us as we build our patients clinical journey?

There are many formats for documentation including:

Narrative reports (usually written in paragraph form) that tell a story of your patient. Good for describing brief interactions or conversations with the patient or other health care providers, or for describing a series of events that need deeper examination.

SOAP notes: Soap is the acronym for Subjective, Objective, Assessment, Plan a series of headers used to document any problems, collect relevant data (for example observations/clinical findings, come to a logical conclusion of the situation and then make some sort of interventional plan.

SBAR: modified for use in the health system, SBAR  stands for Situation, Background, Assessment, Recommendation. It was originally developed for the aviation industry.
Useful for providing consistent handovers of clinical information or for helping you sort out the important stuff from the background noise (for example, when giving information over the phone to a doctor about a quickly deteriorating patient).

Electronic templates: we are seeing more and more electronic documentation via PDA’s and COW’s (computers on wheels). Many of these use some form of standardised data entry template or program to speed up the whole process.

Over the course of their careers, most nurses will develop their own templates for assessment documentation. Some like to go by systems (CNS, Cardio, GIT etc) others prefer an ABC approach.

Here is an example of the way I document patients assessment and progress in the emergency department. I also use a lot of narrative reporting for times when my internal template isn’t going to cut it.
This documentation is in addition to the usual observation chars, fluid balance charts etc.
Remember to follow the documentation policy of your own hospital and to only use acceptable abbreviations (these examples are probably best omitted!!).

Initial Assessment:

History of presenting problem.

  • Why has this patient presented to the emergency department?
    Consider using SAMPLE (Signs and symptoms, Allergies, Medications, Last oral intake, Events preceding presentation.)

Airway: (and c-spine)

  • Is airway clear?
    Does the patient have an airway adjunct in situ?
  • Is the patient at risk of spinal injury?
    Do they have existing c-spine immobilization? Do they have any posterior midline tenderness on palpation?

Breathing:

  • What is the patient’s respiratory rate, rhythm, depth and effort? Eupnoeic = (normal) respirations.
    Is there symmetrical chest excursion? Observe for equal chest rise.
  • Is the trachea mid line? (TML). Deviation of trachea may indicate tension pneumothorax.
  • Is there equal air entry?
  • Are there any audible adventitious breath sounds?
    EXAMPLES: Stridor: upper respiratory obstruction
    Wheeze: lower airway narrowing
    Grunting: patient attempting to generate PEEP. Sign of severe resp distress.
    Remember: Volume of noise in not an indicator of severity.
  • Is patient able to talk in complete sentences?

Circultation:

  • What is the patients pulse rate and rhythm? EXAMPLE: “Strong, irregular radial pulse”
  • What is their monitored rhythm? EXAMPLE: “Monitor: AF with vent response = 110”
  • Non-invasive blood pressure. Document if they are hypo, hyper or normotensive.
  • Are they actively bleeding?
  • Is there evidence of peripheral or central changes in perfusion? (Remember these are late signs!) EXAMPLES: Pallor, cyanosis, dusky, mottled.
  • Capilliary refill.

Disability:

  • What is the patients Neurological Status? AVPU (Alert, responding to Voice, Pain or Unresponsive.)
    GCS and pupil reactivity.

Environment:

  • Does this patient have a temperature?
  • Do they have any rashes?
  • Is their skin sweaty or dry? Diaphoretic = sweaty.

Input:

  • What has the patients oral intake been?
  • Do they have IV fluids running?
  • Have they been administered medications pre-hopital?

Output:

  • What as been the patients urine output?
  • Is the urine dark, cloudy, offensive to smell?
  • Is there an IDC/SPC in situ?
  • Has the patient lost fluids via vomiting, diarrhoea?

Pain:

  • What is the patients subjective pain assessment? Description, location and severity of pain.

Other:

  • What else do you need to document?
  • Deformities, Open Injuries, Tenderness, Swelling (DOTS).
  • Any interventions that may have already been attended.

Ongoing Documentation:

Assessment or Activity:

  • Are there any changes to the patient’s condition since last entry? Reassess ABC’s if necessary.
  • Has something happened that needs to be documented? EXAMPLES: Relevant conversations with patient. Presence of family etc.

Plan:

  • What is the immediate plan for this patient? EXAMPLE: “Pt is awaiting CXR and review by cardiology registrar. For serial ECG, cannula and blood tests.”

Interventions:

  • What are you doing for this patient?
    Every time you do something, document it. EXAMPLE: “ED registrar notified that patient has not yet been seen by doctor. ECG attended”

Outcome:

  • What are the results of your interventions?

16 Responses to “a nursing documentation template.”

  1. love this article. im a new er nurse resident and im trying to learn how to document consistently and accurately. thanks again!

  2. I am first year Nursing student, right now we are learning how to document I didn’t know what to document and what not to document. From this example given,I understand more better how to document but question is, Is there order of how to this document.
    thank guy for putting this online, it’s great
    thank
    pete

  3. have had difficulties choosing any one method of documenting. but this article fits right up there among the best…i think i’ll stick to this method for a long time. thanks much

  4. Hey Ian,
    Just wondering if you have any references re: use of the systems approach for nursing documentation? That’s how I and all my friends were taught to document, but we currently have a group assignment to do, and can’t find a reference for it ANYWHERE!!! (incidentally, typing “how to complete nursing documentation systems approach” into google yields this as the first hit!)
    Much obliged if you have anything!
    Jess

  5. Hi Ian,

    I loved this. Concise,simple to use. I am always confounded at the number of nurse specialist positions we have created and yet none that specifically examine quality assessment and documentation. It is a task which is often assigned to roles which are overloaded with a plethora of time critical reporting and thus takes a back seat. Anecdotally our documentation is definitely not reflecting the quality of our nursing practice. This would be a quality tool to attach to notes as a prompt.

    Cheers

    Nicola

  6. Thank you,
    I started in an ed/outpatient department in rural Queensland only a week ago and have been worried about my notes/assessment of patients.
    Ever since I have been doing ‘google’ searches with every type of nursing/documentation/ed reference, but getting nothing that really answered my questions.
    Your website, and the information on it, have been great. Funny and easy to relate to, it is a refreshing and informative site. Well done.
    Thanks again, and have ‘liked’ you on Facebook for all my nursing mates.
    Shona

  7. Immediately printed this out and used it at work – am in my third week of new job in emergency – got some great feedback about my documentation today! Thanks so much for a wonderful template. I plan to use this for a long time to come.

  8. This is gold Ian. Exactly what this 2nd year student wanted for revision. Thanks!

  9. I wish documentation was governed by patient care instead of KPI’s-Symphony is a good example. the art of a good narrative and and even better verbal handover is lost. The idea of an articulate nurse or paramedic is a dying breed the more dilute our profession becomes………clinical nous and situational and social awareness are no longer the backbones of good documentation and handover.

  10. In the UK the problems identified on our care plans contained a reference number (1,2,3,etc). Whether electronic or printed the actions alongside each problem were visible at all times.

    When we documented, we had to quote this reference number in the margin, then evaluate alongside (eg problem 1, which might have been pain we would write what was given response and side effects during every shift). Works very well, is logical and easy to follow and to trace back response over several days and it ensures the evaluation is related to the actual problem.

    I find with our present ‘systems’ assessment, there is no real correlation to the identified problems, and thus the ‘care plan’ becomes simply a task list, and the actions contained in the care plan are never read. This means the rationale behind the care is often not understood. There is also no requirement for nurses to complete a nursing assessment in less than 24 hours after admission. How is it possible to plan safe care without an immediate and comprehensive assessment.

    I like the terms COW’s =)

  11. Here is one i developed while working Trauma wards to aid in remembering all i had to doucment for the shift…

    V Very Vital signs (RR, Spo2, Hr, B/P, Temp, BM etc)
    N New Neurological status (GCS. AMT, confusion etc)
    P Patients Pain score (using P.A.I.N. assessment tool)
    W Want Wounds and pressure areas
    M Morphine Mobility (i.e. indep, crutches, hoist, bedbound etc)
    N Nearly Nutrion
    E Every Elimination (bowels AND bladder, + vomiting bile etc)
    H Hour Hygiene (indep wash, bed bath etc)
    L Lessening Labs (comment on devitions or that devations passed to Dr)
    S Symptoms Social concerns and discharge planning
    O Of Observational – basically a miscellaneous entry not covering that from previous
    P Pain Plan of care outstanding (list any outstanding jobs needed for that patient etc)

    • This is good and you can capture the joint commission standards like pain, labs, social to include feeling safe at home or do they feel depressed and d/c planning… We are looking at what do we document and is it all necessary… In an attempt to spend more time at the bedside…

  12. Hey this was good we need a formalized way of documentation so some of us will not get into trouble.

  13. Ian,
    This article was very informative. My co-workers and I have performed electronic documentation via the WOWs that are provided for us. We have utilized different forms of documentation such as Narratives,SBAR and PEW scoring in our institution which have proven to be great. Thanks!

  14. Ian

    This is a concise explanation of correct documentation for nurses.

    Nurses across Australia should refer to these principles often.

    Erica

  15. Ian,
    Wonderful stuff and well put together.

    Thank you for bringing me up to speed. I will share you ‘info’ with my colleagues in Europe.

    Cait.

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