Nursing Documentation Policy

Nursing Documentation Policy

Effective Date: [Original NPP Date]
Revised Date: [Current Date]

Goal

To accurately document the resident’s condition and nursing care provided.

Policy

Licensed nursing personnel will document information related to the resident’s condition and care provided in the resident’s medical record.

Procedure

General Rules of Charting

I. Clarity and Precision:

1. Notes must be clear, concise, and not subject to misinterpretation.
2. A narrative note is written for any change in condition, with the frequency of documentation dependent on the individual resident’s condition. A q shift note is required until the situation is resolved.
3. All narrative nurses' notes must include the date, actual time written, and the legal signature of the person making the note.

II. Signature Requirements:

1. Entries made on the Narrative Nurses’ Notes must be signed with the true legal signature of the person making the note, i.e., the initial of the first name or the first name in full and the last name in full, along with the title R.N. or L.P.N.

III. Error Correction:

1. Errors in charting are not erased. A line is drawn through the error, and “error” is written above the crossed-out words. The notation is then rewritten correctly and properly signed. The use of “White-out” is illegal.

IV. Resident-Specific Notations:

1. The word “resident” need not be used on the chart. The chart is a record of each individual resident, and all notations made are specific to that resident.

V. Record Keeping:

1. All resident record forms are kept in the resident’s medical record. After 30 days, non-current nurses' notes may be temporarily removed and placed in a file, with the exception of the admission nurse's note. At the time of discharge, all nurses' notes are included in the completed discharge chart.

Documentation Requirements

I. Admission Notes:

1. Date and time of admission.
2. Any pertinent information not covered on the Nursing Admission History.
3. Who accompanied the resident.
4. Name of physician notified of admission and time notified.
5. Signature.

II. Discharge Notes:

1. Date and time of discharge.
2. Mode of ambulation, noting assistive devices (e.g., ambulatory, wheelchair, stretcher, cane).
3. Mode of transportation (e.g., ambulance, car, taxi).
4. Who accompanied the resident.
5. Where the resident was discharged to (e.g., name of hospital, agency, home).

III. In-House Transfer Notes:

1. Date.
2. Transferred from.
3. Transferred to.

IV. Incident/Accident Documentation:

1. Any unusual happening or situation that could result in bodily injury or property damage must be charted in the nurse's notes.
2. A reportable events form (incident/accident report) is also completed, however, the narrative nurse's note should not mention the completion of the A/I report.

V. Treatment Documentation:

1. The type and resident response, if appropriate. (May also be recorded on the Treatment Kardex if permitted at the facility, instead of in Narrative Nurses Notes).

VI. Physician Service Requests:

1. Time the call was placed and contact made.
2. Specific physician nurse spoke to.
3. What the physician was notified of.
4. Action taken by the physician.
5. If unable to contact the physician, chart the action taken by the nurse.

VII. Reactions and Notifications:

1. Chart all untoward reactions related to medications, feedings, treatments, therapy, changes in the environment.
2. Notification of family must be charted, including:
   • Time the call was placed and contact made.
   • Specific family member spoken to.
   • What the family was notified of.
   • Recording of action taken by the nurse and resident’s response to it.

VIII. Other Documentation:

1. Administration of prn medications or treatments (may be recorded on the back of prn medication or treatment Kardexes as permitted at the facility, instead of in Narrative Notes).
2. Emotional support or counseling given.
3. Referrals to other facility services – recreation, social services, etc.
4. Teaching or training given.

References:

• Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP - Guidance to Surveyors for Long-Term Care Facilities. [Link to current CMS SOM]
• CMS Requirements of Participation for Long-Term Care Facilities. [Link to current guidelines]