5 Tips for Nurses to Overcome Challenges in Maintaining Nursing Notes
Great note taking is a vital tool of communication between nurses, doctors, and patients to ensure that the patient’s health care record is an accurate account of care planning, treatment, and delivery. No matter what nursing field you’ve specialized under, the importance of taking contemporaneous notes is crucial to ensuring patients receive the highest level of care.
Without high quality nursing notes it becomes difficult to find clear evidence of planned care, medical decisions made, information shared between colleagues, and the care delivered to the patient. Having this information readily available is very important as medical records are a potential legal document that could be used in court.
Increased Scrutiny towards Nurses
Since legislation such as the Human Rights Act of 1998 and the Data Protection Act of 1998, nurses are subjected to more investigation regarding their record keeping. This is due to the fact that these two legislations have increased patient access to health records. The increased visibility of nursing notes results in an increase of patient complaints about their care.
Taking contemporaneous notes isn’t just about a matter of quality should medical records be required for a legal case. It’s also legally required for nurses to take notes within 24 hours of events. Notes should be taken as soon as possible to ensure that important details regarding the care delivered to the patient get recorded. Without clear and readable nursing notes finding evidence that could stand trial may become a challenge should a patient decide to pursue a dispute further.
Although some complaints can be resolved by health care providers, the possibility of settling disputes in court is always a possibility. Should this ever arise on a patient you helped care for you want to be sure that contemporaneous notes are maintained on all patients whenever takings notes are necessary. Recalling small details in nursing notes at the time of care will provide clear evidence that will answer questions quicker.
5 Tips to Improve Note Taking
Due to the potential legal nature of nursing it’s important to take the highest quality notes on all patients. This can be a challenge due to the volume of patients that can be seen on a daily basis. However keeping high quality notes will greatly reduce the amount of risk you, your colleagues, and the medical facility will endure when disputes on the level of care arise. Keeping contemporaneous notes should be a matter of habit and adopting the following tips will make improving and maintaining the quality of your nursing notes much easier.
- Be Objective
When maintaining notes on patients it’s important that you record accurate, factual, and unambiguous information. Everything that you record has to be able to stand under trial should that event ever occur. For example using jargon or simple expressions such as “The patient had a good day” should never be used as it’s too ambiguous to provide clear evidence to the care the patient received. Expressions such as these should never be used unless it’s backed up by facts. This doesn’t mean that expressions such as these can never be used it just means that it should never stand alone. A better example would be “The patient had a good day when family visited after being served lunch by staff”. This example provides facts which give further detail into why the patient had a good day and how the staff played a role in the care received.
- Use Your Senses
One of the benefits of taking contemporaneous notes is the level of detail that you’ll be able to recall. By incorporating your senses into your nursing notes you will also draw in anyone reading your notes. This means that staff reading your notes after you will be more engaged and focused in the care of the patient and legal staff reviewing your notes will find a clearer picture of the quality of care provided to the patient. Knowing what to write for so many patients may sometimes be a challenge when encountering a routine day where nothing exciting or different happened. Anchor your notes with details involving your senses by starting sentences with phrases such as “I saw”, “I heard”, or “I felt” to maintain your focus throughout your work shift and provide a higher level of quality to your nursing notes.
- Quoting Patients
Quoting patients is a powerful detail that should be added to contemporaneous notes whenever possible. The punctuation marks stand out and maintain the attention of anyone reading your notes while providing clear evidence of interactions between you and the patient. Quoting is not only great for grabbing the attention of sleepy staff working the shift after you but can also become an important tool in a legal case.
- Provide Evidence
Every time medical records are updated with new information it’s important to view your notes as potential legal documents that may have to be defended. It helps to justify your actions in the course of creating your contemporaneous notes. By justifying your actions in the nursing notes themselves you provide a more reliable means of justification. When working shifts it’s important to keep track of any courses of action that are taken which could have legal ramifications.
For example if you are a mental health worker and you had to deny the patient visiting rights you may write something as follows “Visiting rights denied to patient today as verbal threats were made and physical intimidation occurred towards family members who admitted them. Family was sent home early and the patient was allowed extra time in the Quiet Room to help them calm down”. It’s during times like these where being objective becomes very important to make sure your contemporaneous notes stand should they become part of a trial.
- Document Objections
It’s possible that during the course of your career as a nurse you will encounter medical decisions that are made by staff that you don’t agree with. It may not be common but it’s a possibility that you need to protect yourself should you find yourself in that situation. In these situations it’s important to be as objective as possible and provide as much evidence as necessary to protect yourself from incurring blame in your nursing notes.
Take Notes Immediately
One of the biggest lies we tell ourselves is “I‘ll remember that”. It’s not wise to rely on memory to keep track of everything that happens. Taking notes immediately after events increases their reliability and maintaining the habit of taking contemporaneous notes will only increase the level of responsibility you take for the care of patients in the eyes of colleagues and legal staff. As a nurse you see hundreds of patients in a day and have different levels of interactions with each one. You can’t hope to recall important details about a particular patient without taking detailed notes. Though the importance of taking quality nursing notes is clear nurses face a lot of challenges when maintaining a patient’s medical record and describing the level of care they rendered to each patient.
Challenges in Taking Notes
Besides being responsible for the care of patients which could result in ethical or legal problems there are many reasons why a nurse would find taking and maintaining contemporaneous notes on all patients a challenge. Though the legal issues should be enough of a reason for any nurse to maintain the highest level of quality there are numerous reasons why maintaining notes is a challenge. Some of these reasons are as follows.
Lack of Patient Involvement
Whenever possible nurses should involve patients into their nursing notes to show that they are concerned with the care patients receive. However there may be patients who are unable to be involved or choose not to be involved for different reasons. This lack of involvement after time makes it easy to lose focus and forget the importance of involving the patient into their contemporaneous notes. Due to the volume of patients a nurse handles in a shift a nurse will have difficulty recalling details of patient involvement but interactions will be fresh in the patient’s mind. It’s important to find a way to get patients involved in their care so objective nursing notes can be maintained if they are ever needed for a dispute.
There are two types of staff in a medical facility. The kind that can’t read anyone’s writing or the kind that produces illegible writing. If you find reading others handwriting easy then you may be the former type that produces hard to read writing. Improving handwriting is something that takes time and slowing down during the writing process. Unfortunately due to the volume of patients that are seen in a day slowing down may not be possible. Without slowing down creating handwriting that’s easier to read in your contemporaneous notes becomes much more difficult.
Maintaining the highest quality nursing notes that could be used in the event of a dispute or legal case on hundreds of patients seen on a daily basis is very time consuming. A nurse can’t spend all of their time writing notes as its necessary for care to be rendered to patients so they have something they can write for notes. Though maintaining contemporaneous notes becomes easier when written immediately after care is rendered, the volume of patients makes it easy to get overwhelmed and makes taking dangerous shortcuts on documenting patient care tempting.
Hard to Add Graphics
A picture is worth a thousand words and adding them to handwritten notes can become a difficult challenge unless printouts with premade graphics are created. Even then adding printouts to a messy file isn’t a wise choice when a medical facility can see hundreds, maybe thousands of patients in a day. In order to ensure medical records can be kept neat and available for disputes and legal cases a more modern system has to be utilized.
Lack of a Modern System
Many medical facilities are adopting software systems to make the process of maintaining contemporaneous notes easier on nurses. Software addresses many of the challenges nurse’s face when maintaining high quality nursing notes such as illegible writing, the amount of time it takes to write notes, and adding graphics.
Though patient involvement may always be an issue, software addresses many of the challenges nurses face when maintaining notes. Not having a modern system can increase the challenge a nurse faces when maintain patient records and maintaining patient records is an important of delivering the highest level of care to every patient.
Without accurate records it’s not possible to recall all the details for every patient. Should those details ever be required for a legal dispute, vital evidence regarding the patients care will become unclear and the course of the dispute will take a different and undesired course. It’s easy to take shortcuts on maintaining nursing notes but keeping these 5 tips in mind and remembering the 5 challenges to overcome will ensure a vital tool in patient care will no