Care documentation - tips for greater efficiency

Care documentation? Everyone knows it. And everyone knows how much work and complexity is often behind it. But in this article, you will learn why it is so important and how care can be documented more efficiently and quickly.

 

 

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, searching for clues, but the notes of his predecessors are much ado about nothing. His shift is almost over, the lady looks sad. Isn't there any way to make all this more efficient?

 

 

Why is nursing documentation so important?

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. Therefore, complete written documentation of care is essential for the correct and appropriate care of a person.

 

Even though care documentation may at first glance appear to many nursing staff to be a tedious task that is carried out repetitively and routinely, it often fulfills an important purpose. After all, the main purpose of keeping notes is to pass on and record information.

 

From time to time, symptoms suddenly appear in a patient 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, this hidden information can often be used to find out what is really wrong with the patient.

 

 

Tips for meaningful documentation

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.

 

Patient is bright and alert.

 

Patient did not want to eat. Patient had a bowel movement. Zack, done, folder closed, end of shift. Or not?

 

Proper and accurate representation of the date          

• A patient's care doesn't always go according to plan. The person may be angry or reluctant, may not want to be washed or may stubbornly avoid any communication. But even if it costs nerves: Care documentation should never be judgmental.

 

• It is better to break down every aspect and every important action to its most rational content and to reproduce it as neutrally as possible. For example, instead of writing: "Patient very stubborn and cheeky today", a statement that describes the situation more accurately and without emotion would be more informative for the next caregiver. "Patient refused to get up." in this case, for example, could indicate that there is pain in the legs or feet and is more suitable for passing on information.

 

Reduce to the essentials

• Often it 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 like: "The patient ate." or "The patient helped." unless it is a personal progress of the person being cared for.

   

  Noting everything that has been done is completely sufficient and causes less confusion than a long but meaningless text. Many things that are documented should not actually be assigned to a nurse.Find out more.

 

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 a long time or even have other patients in the meantime, you often no longer remember the details. As a result, you sit at your desk in the evening and ask yourself: "Was it the left or the right arm on which I noticed hematomas? Did I make sure the patient took the heart medication?"

 

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 caregiver exactly as intended.

 

Continuous, correct, complete        

• What many people rarely realize: Care documentation is considered a document. Accordingly, there are important basic rules that must not be neglected under any circumstances.

   

• This includes the accuracy and completeness of the report. Omitting information or even writing something down incorrectly because of a small time window is therefore not an option. In addition, a patient's care should be as complete as possible so that the progression can be presented realistically.

     

Images as a means of documentation

• If you discover important indications of injuries or illnesses on the patient's body or in their surroundings, images 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 nurse 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.

   

Would you like to know more about how you can better document your care visits? Leave a comment right away!

 

Increase efficiency

 

If there is little time left per appointment, there is the option of temporarily updating the information mobile on your smartphone to be noted. There are now some good apps for nursing staff that offer a dictation function and electronic documentation options, among other things. This means you can relax and devote yourself to your nursing work and fill out the correct documentation sheet as soon as the service draws to a close. We recommend the program Coredinate, which also offers many other services and makes working as a caregiver a little easier.

 

Also a good way to shorten the documentation time is the structure after W-Questions. They are familiar from childhood, when you 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 it for too long.

 

Who was cared for, who ordered which treatment, who carried out 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 maintenance steps carried out? Where and when did the appointment take place? All these questions will help you fill out the form and save time.

 

Nora's Tip:Not only can you manage your time better -here learn how to save money efficiently!

 

The most important W question: How do I find the patient who will benefit most from my knowledge? noracares helps you to be able to use your expertise for the benefit of a human being!

 

The right structure 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.

 

Here the structure according to the principle: "Incident - Action - Event" helps. 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."

 

Tips for relatives

 

Family members and friends of a person in need of care can also contribute a lot to the correct care documentation and thus support the care process. People who live close to the patient are often more familiar with details about behavior and health problems. At the end of the appointment, talk to the caregiver about the documented situations. This can clarify any unclear behaviors of the person being cared for, for example, and the caregiver can better assess the person they are supporting.

 

Important: If you suspect that the nurse is not mentioning or incorrectly describing something in the care documentation, it is best to talk about it openly. This is about the health and enjoyment of life of a person who is important to you.

 

Nora's conclusion

 

• The care documentation can often allow conclusions to be drawn about the causes of illness or initial signs and symptoms. It is therefore important to fill it out according to all important rules and regulations.

 

• Validating or superfluous statements do not belong in the care documentation. It is better to briefly and concisely record the most important information.

 

• Photographs can also be a good additional means of documentation, provided the photos were taken in accordance with certain regulations.

 

• You shouldn't wait too long to create the documentation. However, if you're in a hurry, you can use an app to record the course of the appointment so that you don't forget anything important.

 

• Formulation aids and following certain schemes can significantly increase the time efficiency of care documentation.

 

Would you like to help people in difficult life situations with your caregiver and help organize your own working hours? Find here the person who needs your skills the most!