Organize Your Entries

It is not always easy to make documentation a priority.  Time constraints may lead you to think that other patient care activities are more important, particularly in a crisis situation.  Often documentation is pushed to the bottom of the list of priorities.  To help prevent documentation from becoming a burden, organize patient care information into categories.

If  you have other areas that work for you, please share them!

What the patient tells you.This is information you obtain directly from the patient or from the patient’s representative if the patient is incapacitated in some way.
What you assess.This is the information you collect from performing your physical assessment. It includes vital sign measurements and inspection, palpation, percussion and auscultation.
What actions you take in response to your assessment.The interventions you perform. Interventions may be dependent, interdependent, or independent.
The patient’s response to your interventions.The patient’s response may be favorable or may be an abnormal or deterioration in response to treatment or therapy, which would then require a modification in the plan of care.
What you teach your patient / family.The health information or instructions you give a patient or their family. Health information is expected to be provided in a manner that is meaningful and useful to patients i.e. health literacy factors.

Leave a Comment

Your email address will not be published. Required fields are marked *