How do you approach the documentation of patient records? Do you have specific strategies that you use?

Question

Kelly Burlison · Accepted Answer

"I am new to nursing, as I just finished nursing school, but I understand how important clinical documentation is. During my clinical rotations, when I had the opportunity to document my clinical encounters, I made sure to document everything, and before signing the note, I would double-check to ensure everything was correct. Since I am new to this and have not had a chance to develop my own efficiencies, I cannot speak to that, but I can say that my background in IT project management will allow me to think outside the box, and I can see myself coming up with ideas for standardization that others may not ever think of."

Kelly Burlison · Answer

Documentation of clinical encounters in patient records is extremely important and much of this responsibility rests on the shoulders of the nursing staff. If clinical encounters, medications, procedures, vital signs, and other information is not documented properly, unintended consequences could occur, some being dire. The interviewer is asking this question to determine how seriously the candidate takes documentation and to determine if they use any methods to improve efficiencies for documentation. To effectively answer this question, the candidate should talk about how they approach documentation, from beginning to end and give examples of any strategies they use to improve efficiency.

Kelly Burlison · Answer

"Documentation can be hard, especially on the days when I am extremely busy and I feel like I hardly have time to give basic care to my patients. While I know that I have to fill out the clinic notes completely, I also do not always have time to complete the full note at the patient bedside. What I will do is fill out the basic information and save the note so I can go back and edit it later. Then, when I have time later in the day, I will go back and complete the note using the shorthand notes that I left myself in the medical record."

Kelly Burlison · Answer

"Working in a pediatric outpatient clinic, what I spent the most of my time on is documenting vaccines that were administered. This is not just the case for me, but all my pediatric nursing colleagues at work, we were spending a significant amount of time documenting vaccines. There were instances of other nurses taking shortcuts to save time, but these shortcuts did not include all the required information. Since this was such a big issue, I was always trying to find ways to help us streamline the vaccine documentation process, and one day, as I stood in the vaccine room, I came up with an idea of scanning the barcodes on the vaccines and them going straight into the medical record. While this idea took a long time to execute and a lot of work, I was able to work with our EHR and IT staff at our company to make this happen and it has freed up a significant amount of time for all pediatric nurses."

Kelly Burlison · Answer

"Several years ago, when I first started working in outpatient adult medicine, I found that I was spending a significant amount of time writing clinic notes, and many days, I was writing the same things repeatedly. I know how important clinical documentation is, for everything from clinical decision-making to quality reporting, so I knew I needed to write thorough records. So, to help myself save time, I wrote out templates that included the basic information for different types of visits, such as sick visit, well visit, diabetes follow up, and senior visit, and saved them on WordPad so I could copy the information into the EHR. Now, when one of these patients comes in for an appointment, I am able to copy in the template and fill in the blanks. This process saves me a significant amount of time and my documentation is of good quality."

Tabitha Cumpian · Answer

"When I begin documenting I always think about how I can chart everything that happened in the most comprehensive yet concise way. I prefer to use flowsheets when the EHR has them available. Then, unless specified by the organization, I always chart by exception. I feel this makes documenting more efficient. I document as much as I can by exception and with the flowsheets. If I need to document something that does not easily or smoothly fit into a flowsheet, then I will add a nursing note. I have found that this process has streamlined my documentation."

Anonymous User · Answer

"I approach patient documentation very seriously because I understand the importance of proper charting. In my practice during preceptorship, I used a wow station which I would take with me into the patient's room. I would perform the assessment and chart in the patient's room as soon as I completed it. This kept my charting true to the time and allowed me to see if my patient had any complications or improvements."

Anonymous User · Answer

"Since I am a new graduate, I haven't necessarily found specific strategies when it comes to documentation; however, I am well aware of just how important accurate and concise documentation is. In school, I've generally stuck to documenting everything, even normal findings, instead of documenting by exception like most systems use."

How do you approach the documentation of patient records? Do you have specific strategies that you use?

How to Answer: How do you approach the documentation of patient records? Do you have specific strategies that you use?

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6. How do you approach the documentation of patient records? Do you have specific strategies that you use?

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