Importance of Documentation
Documentation is crucial for patient care reimbursement from insurance companies.
Accurate notes are critical, especially if an incident occurs involving a patient.
Review of notes may occur if issues arise, highlighting the need for thoroughness in documentation.
Use of the 24-Hour Clock
Always document using military time (00:00 to 23:59).
For example, use 14:00 instead of 2 PM, 16:00 instead of 4 PM.
New day begins at 00:00 (midnight) and ends at 23:59.
Types of Information to Document
Documentation should include both subjective and objective data.
Subjective Information: What the patient reports (e.g., "I have chest pain").
Use quotations around subjective data, e.g., Patient states, "I have chest pain."
Objective Information: Observations and measurable data.
Documenting in Real-Time
Always document when care is provided, not at the end of the day.
Immediate documentation ensures accuracy and detail retention.
Delaying documentation increases risk of forgetting details or missing data altogether.
What Not to Document
Never document opinions or personal interpretations.
For example, do not say, "I think the patient might be in pain."
Avoid generalizations.
If an event occurs (e.g., a patient falls), document the event factually.
Example of Proper Documentation:
Instead of "Patient fell," state "Patient found lying on the floor."
Quotation marks for subjective statements.
Timely documentation is essential for care accuracy.
Avoid subjective wording in observations.