Documentation Guidelines : A summary of when to document what
Admission
Beginning
of Shift
• Complete Admission History in StarPanel within 24 hrs. of admission
• Assess ALL Care Categories, noting baseline status. If using WEL& OEL enter an annotation with supporting information.
• Document Care Contact & VUMC general & unit specific orientation in Education Tab
• Assess Care Categories in ALL CAPS + others based on problems or risk for problems
• Denote Priority Problems for shift w/ !! & set goals for each priority problem.
• Document Interventions in real time or near real time through the shift.
• Document either “unchanged” or “unchanged except” & denote changes for OEL, problems, risk for problems or based
on orders &/or nursing judgment. DO NOT document on those wnl.
Focused Re- • ICU – at least two more times during the shift
assessment • Acute Care – at least once during the shift
PreProcedure
or Transfer
End of shift
Discharge
• Focused reassessment, note new, resolved, or unchanged problems
• Summarize response to care focus on priority problems; Identify issues for f/u by receiving nurse; avoid duplication
• Enter interventions, vitals, I&O, & meds
• Summarize response to care focus on priority problems; Identify issues for f/u by receiving nurse; avoid duplication
• Ensure all assessment, interventions, vitals, I&O, meds documentation is up-to-date
• Summarize response to care, focus on unresolved problems and action plan post discharge; avoid duplication
• Ensure all assessments, interventions, vitals, I&O, meds documentation is up-to-date
NEED TO KNOWS….
Modified Charting by Exception – To reduce repetitive charting of normal assessment detail ,
nurses chart within normal/expected limits (WNL, WEL) for each care category omitting normal
findings except for normal values needed for decision support (Braden, Morse, RASS).
WNL – Within normal limits. Meets standard criteria for developmental age. Use Hover over
feature to display WNL criteria.
WEL – Within expected limits ( previously baseline). Does not meet all the standard criteria for
development age, but is expected for patients in this clinical phase (post-op) or normal for
patient. Does not require measures beyond the standard of care. Requires supporting
documentation of finding upon admission assessment only ( example- Right AKA x 4 years, non
symptomatic a fib x 3 years, groggy from anesthesia for immediate post op pt)
OEL – Outside expected limits - Does not meet criteria for WNL or WEL but has not risen to the
level of a problem. Need to continue to evaluate to see if problems develops. No additional or
special care needed except to include this in the next focused assessment. (example-hypoactive
BS but no other GI Issues, tachycardia for pt w/ fever, jaundice for pt with liver failure) Requires
supporting documentation of findings with each shift assessment.
Problems (Nursing diagnoses) require targeted interventions and should be a significant focus of
the plan of care (eg. Incision) Requires supporting documentation of findings with each shift
assessment
Priority problems Priority problems are flagged in red and represent the most important shift
focus based on patient (eg pain), team (eg oxygenation) and nurse’s assessment of risk (eg skin
integrity) . They require measureable goals and outcomes are described in the Response to Care
narrative statement. Requires supporting documentation of findings with each shift assessment.
Interventions – Reflect implementation of the plan of care (Assess, Care, Teach, Notify) based on
provider orders, VUMC Policy & Procedure, and published Nursing standards of care (ie Mosby).
My Notes:
Assessment Documentation
All care categories require documentation on admission.
Assessments shown in all capital letters are required
documentation every shift. Focused re-assessment is done if the
initial assessment for that category was outside expected limits or
if the patient unstable, is at risk for, or has an existing problem
for that care category.
Data Display
Before you click on “chart” the display of the data has been
collapsed to facilitate easy viewing.
Data displays in 1 hour increments
VS/I&O
Assessment
Interventions
Pain/CDR
Device
Protocols
Displays in 12h increments
Plan
ALL DOCS
Displays in 24h increments
Education
FOCUSED
REASSESSMENT
if problem/risk
if problem/risk
if problem/risk
CARE CATEGORY
ADM
QSHIFT +
- PAIN
- NEURO
- CARDIAC
X
X
X
X
X
X
- Vascular/Perfusion
X
- RESPIRATORY
X
X
if problem/risk
GASTROINTESTINAL
X
X
if problem/risk
X
X
X
X
X
X
if problem/risk
if problem/risk
if problem/risk
- SAFETY/FALL RISK
- SKIN/WOUND
- URINARY/RENAL
Activity/Musculoskel
etal
- Fluid/Nutrition
- Medication
if problem/risk
X
if problem/risk
X
X
if problem/risk
if problem/risk
Infectious/Metabolic
X
if problem/risk
- Psychosocial
- Reproductive
- Self-care (ADL)
X
OB
X
if problem/risk
if problem/risk
if problem/risk