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. |
