Care documentation - tips for greater efficiency

Efficient care documentation saves time and nerves! Get practical tips for structured and complete care documentation. This will make it easier for you to collaborate with other nursing staff.

Nursing documentation is far more than just a mandatory part of everyday nursing care - it is the heart of empathetic, quality-oriented care. Whether in hospitals, nursing homes or home-care: Complete and thorough documentation not only ensures the best possible care for your loved one, but also creates trust between nursing staff, relatives and patients.

However, many nursing staff feel unsure when it comes to recording all relevant information correctly and in a legally compliant manner. Clear, comprehensible and complete care documentation is the key to making care processes transparent, identifying risks at an early stage and complying with legal requirements.

In this article, you will learn step by step how to create professional care documentation - from the most important content and legal principles to practical tips and helpful templates. In this way, you can improve the quality of care with certainty and confidence while legally safeguarding your responsibilities. Read on and discover how you can not only make everyday care easier with the right care documentation, but also really shape it.

Care documentation? Everyone knows it. And everyone knows how much work and complexity is often involved. However, the main purpose of keeping records is to pass on and record information that goes far beyond a chore.

Niklas is sitting in front of the documentation sheet. He actually wanted to take the nice elderly lady sitting in the wheelchair at the other end of the table for a walk through the park so that she could get some fresh air. But writing down all the information takes time - and the patient is also complaining of sharp pains in her shoulder. He looks through the documentation of the last nurses again, looking for clues, but the notes of his predecessors are a lot of talk about nothing. His shift is almost over, the lady looks sad. Isn't there any way to make all this more efficient?

The Care Documentation is the foundation for needs-based, quality-oriented care. It serves to ensure continuous and needs-based care and supports communication within the care team. Caring for a person is not just about providing help and support with everyday activities. Above all, it is also important to recognize illnesses or problems at an early stage and to be able to track the progress of the situation that makes the person a care case in the first place. Complete written documentation of care is therefore essential for the correct and appropriate care of a person.

From time to time, symptoms suddenly appear in patients that could have been better understood through continuous care documentation. For example, if a patient experiences abdominal pain during an appointment, this is often not recognized immediately. Sometimes patients do not express their complaints clearly, but react to pain with resistance and frustration, for example by refusing to eat. With proper and regular care documentation, you can often use this hidden information to find out what is really wrong with the patient.

The care documentation is a document and thus the legally valid proof of the care provided (Source: Arbeitshilfe Pflegedokumentation, Gesundheit Österreich GmbH). Their quality contributes significantly to improving the quality of care and protecting nursing staff (Source: Medi-Karriere Magazin, Pflegedokumentation).

Care documentation includes all relevant information about a person's care, from initial contact to discharge or end of life. Comprehensive care documentation should record all steps of the care process - from care history to evaluation - in a comprehensible and timely manner (Source: DocCheck Flexikon: nursing documentation).

Here are the most important components you should know:

Nursing documentation is not only a matter of good practice, but also a legal obligation.

According to § 5 of the Health and Nursing Care Act (GuKG) in Austria, members of the Healthcare and Nursing Professions obliged to document all nursing measures in a complete and comprehensible manner (Source: GuKG, § 5). The documentation is legally binding and serves as proof of the care provided. In addition, the Data protection laws (GDPR) must be complied with. The care documentation also serves as legal proof and must be kept for at least ten years. It must be made available to the patient or their authorized representative upon request.

Not all care documentation really serves its purpose. Especially after a long shift and many nerve-wracking situations, the temptation to quickly write down all the superficial information is all too great. But this is detrimental to patient safety and can put you under legal pressure.

Here are the most important principles and tips for meaningful and secure documentation:

Principles of nursing documentation

Practical tips for your documentation

1. Timely documentation: In order to be able to reproduce the situation and the process accurately and completely, it is important to record everything important as soon as possible after the appointment. If you wait longer or have seen other patients in the meantime, it is often difficult to remember details.

    

2. Factual and accurate reproduction:The care of a patient does not always go according to plan. But even if it costs nerves: Nursing documentation should never be judgmental. It is better to break down every aspect and every important action to its most rational content and to describe it as neutrally as possible. For example, instead of writing: "Patient very stubborn and cheeky today", a statement that describes the situation more precisely and without emotion would be more informative for the next caregiver. "Patient refused to get up." could in this case, for example, indicate that there is pain in the legs or feet and is more suitable for passing on information.

    

3. Use technical language: By expressing abnormalities or events with technical terms rather than freely emotionally, misunderstandings can be avoided - because general terms, which can often be interpreted in different ways, have a fixed meaning in medical terminology. This ensures that the message reaches the next nurse exactly as planned.

    

4. Reduce to the essentials: It often seems as if nothing much out of the ordinary has happened. The patient behaved as usual, nothing special happened and the treatment generally went smoothly. Nevertheless, you should avoid sentences such as: "The patient ate." or "The patient helped." unless it is a personal progress of the person being cared for. Writing down everything that has been done is completely sufficient and causes less confusion than a long but meaningless text.

    

5. Correct errors correctly: Due to its importance as a document, it is important to correct errors correctly. Cross out errors and write the correction next to them - erasing or blackening is not permitted.

Images as a supplementary documentation tool

If you discover important clues about injuries or illnesses on the patient's body or in their surroundings, pictures can capture what you see better than words alone. However, there are a few things to bear in mind: The name of the patient, the name of the caregiver and the time and date must be recorded on every picture taken. In addition, the photos taken must of course never be used to the detriment of the patient.

When there is little time per appointment, there are now numerous ways to make documentation more efficient.

Handwritten vs. digital care documentation

Many nursing staff now use apps with a dictation function or electronic forms, e.g. the Coredinate program. e.g. the Coredinate program to Documentation time to save time. This allows you to relax and devote yourself to your nursing activities and fill out the correct documentation sheet as soon as the service draws to a close.

Formatting guides and schemes

Another good way to shorten the documentation time is to use the W-question structure. We are familiar with them from childhood, when we were told what information was important in an emergency call - but they are also a great tool for care documentation, allowing you to integrate all the necessary points into the documentation without having to think about them for too long. Who was cared for, who ordered which treatment, who provided the care? Why was this and that done? How was the treatment carried out? What was done at all? How long did it take? To what extent were various care steps carried out? Where and when did the appointment take place? All of these questions will help you fill out the form and save time.

The right layout can also save a lot of time. Situations that arise during a nursing appointment can be incredibly complex, and it is often difficult to put them into words in a concise manner. After all, what is written should also make sense to others and be comprehensible. This is where a structure based on the principle: "Incident - Action - Event". A paragraph structured according to this pattern could look like this: "Patient refused to move his left leg. The leg was palpated. Pain was noted near the knee."

Family members and friends of a person in need of care are often an invaluable source of information for your care documentation. Since they live in the patient's immediate environment, they often know details about behavior, habits and health problems better than anyone else. Their observations can help you to get a more comprehensive picture of the situation and adapt your care in the best possible way.

• Seeking active exchange: Actively talk to family members at the end of your appointment or during handovers. Ask specifically for observations on behavior, mood or special features that they have noticed.
• Integrate information: The information provided by relatives can help you to better assess unclear behaviors of the person being cared for and thus make the documentation more precise.
• How to deal with family concerns: If relatives suspect that information is missing or incorrectly described in the care documentation, an open and transparent conversation is crucial. Explain the importance of the documentation and offer insight where appropriate. After all, it's about the person's health and well-being, which is important to everyone.

Ensure quality of care and create trust with well thought-out care documentation! Careful care documentation is the foundation for individual, safe and appreciative care. It not only enables seamless tracking of all care processes, but also strengthens communication within the care team and with relatives. At the same time, it protects you legally and ensures transparency - a win-win situation for everyone involved.

Although documenting can sometimes seem challenging, with the right knowledge, practical templates and a clear structure, it quickly becomes clear how easy and effective it can be. Use the tips, guidelines and checklists presented in this article to design your care documentation not only dutifully, but with heart and mind.

Think about it: Every carefully kept care documentation is an important contribution to a better quality of life for the people in need of care and a sign of your commitment as a caregiver or Relatives:r. With this knowledge, you are well equipped to fulfill your care responsibilities safely and professionally.

Start today - for better care tomorrow!

• General Data Protection Regulation (GDPR): An EU regulation that governs the protection of personal data and is also relevant for care documentation.
• Documentation obligation: The legal obligation of nursing staff to record all relevant nursing measures and observations in writing.
• Evidence-based: Based on scientifically proven facts and study results that serve to justify nursing actions.
• Evaluation: The systematic assessment of the effectiveness of care measures and the entire care process in order to adjust it if necessary.
• Gesundheits- und Krankenpflegegesetz (GuKG): The law applicable in Austria that regulates the practice of the profession of healthcare and nursing and also stipulates the documentation requirements.
• Hematoma: A bruise caused by bleeding under the skin or into other tissues.
• Care history: The structured collection of information about the health status, needs and resources of a person in need of care at the beginning of the care process.
• Care report:A written summary of the course of care, important events and observations during a specific period of time.
• Care diagnosis: The professional assessment and formulation of an actual or potential health problem of a person in need of care for which care interventions are required.
• Care planning: The systematic definition of care goals and concrete measures to solve the identified care problems.
• Symptom: A sign or characteristic of a disease that can be perceived by the affected person or observed by others.
• Certificate: A written document that has legal probative value. The care documentation is considered such a document.
• W-questions: A questioning technique (who, what, when, where, how, why) that helps to systematically gather all relevant information on a subject.