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?