What is the Difference in the Way that Nurses Document Versus Certified Nursing Assistants?

Nurses use a variety of documentation formats. Not all are permanent parts of the medical record. Listed below are the different formats and a brief description of each. Perhaps you recognize a format used in your own facility? Regardless of the format used to chart, it is a formal, legal document that details a client's progress. Once again, it bears repeating that "if it ain't in the record, it was not done." So make sure whichever format you are using, it is complete and accurate.

Documentation (Charting) Formats

Nursing Care Plans: Most care plan forms have three columns. One is for a nursing diagnosis, a second column is for nursing actions or interventions, and a third column is for expected client outcomes of care. The nurse must develop a care plan for each client usually within a specified amount of time after the client enters a facility for care or service.

Standardized Nursing Care Plans: These preprinted care plans were created to save nurses time that they would normally spend in charting. These plans detail the standards of care for a given client with a particular problem, diagnosis or issue. Examples: A standardized care plan may exist for a patient with a problem such as Constipation Related to Immobility as a Result of Complete Bed Rest Following Bilateral Hip Replacement Surgery or with a diagnosis of Alzheimer's Disease or an issue like Failure to Comply with Prescribed Treatment for Diabetes. The plan is formatted so that the nurse merely has to check off care that is provided. If something occurs that is not already designated on the care plan, the nurse will individualize the care plan to include that issue by writing in a narrative note.

Critical Pathways or Health Care Maps: These tools may be preprinted. They include nursing actions for a client with a specific medical diagnosis. They also specify care that the client should receive on a daily basis including but not limited to diet, medications, activity, treatments, etc. Pathways or maps have become very popular since managed care systems have emerged. They serve as a means of not only documenting but also monitoring care. Variances in providing care or achieving client goals or outcomes by the targeted dates indicated on the pathways is an immediate cause for scrutiny and investigation into the cause of the variances. The goal is to have the client progress according to the pathway or map goals so that the costs in providing that care are reimbursed to the facility by third party payers. Your facility will always challenge you to give the care more efficiently and effectively so that costs are kept to a minimum yet the quality of care remains high. Documentation will remain paramount in systems like this where micro-monitoring is becoming the norm of the day.

Now that you have reviewed some of the most commonly used documentation formats, let's take a look at the various methods that nurses use when they chart or document on any particular format.