First, look at your overall documentation system and requirements. Do staff members need to document every shift or when there is a change in condition? According to federal and state auditors, when reviewing a medical record they are looking for how and when nurses intervene when there is a change in the status or condition of the patient.
Second, I recommend that you look at what is being documented. Is there a format that would assist staff in staying focused on what is most important in their progress notes? Also, avoid redundancy. For example, if the information can be found in a flow sheet, do not have staff repeat themselves. Consider using the FOCUS charting method. Patient concerns are usually identified during the admission assessment or reassessment while being hospitalized. In FOCUS charting, the identified concern is the "focus" of the narrative note. This methodology of documentation assists the writer in remaining on task by documenting what is the Data, what Action did the nurse do for the problem/focus of the note, and how did the patient Respond.
The focus may be any of the following:
|Current behavior or concern
|Sign and symptom
|Acute change in status
|Significant patient care event
Impaired gas exchange
Third, peer-to-peer chart audits can be powerful tools to motivate staff to change. Everyone has a perception that their documentation is concise, timely, and relevant. Building a user-friendly audit tool and sharing the results has worked in many facilities. The staff will want to see how well they are doing and move forward in compliance as a whole.
—Patricia A. Duclos-Miller, RN, MS, NE-BC