Documentation 101
By Marianna Herrera, RN, BSN, IgCN - February 3, 2023

If you didn't document it, it didn't happen! This is the mantra of the fundamentals of nursing—and what an appropriate statement it is!

There are many options available for nursing notes, and they are all developed with the same purpose: to effectively communicate within the healthcare team and provide information for other professionals. This is one reason why there is no "standardized" nursing note for all nursing documentation purposes. It is imperative that nurses familiarize themselves with each specific note. Nursing notes are not "one size fits all" and must be filled out appropriately.

According to the American Nurses Association, high-quality (nursingworld.org) documentation must meet certain characteristics to be used effectively to communicate and provide essential information. Nursing notes must be:

• Accessible
• Accurate, relevant, and consistent
• Auditable
• Clear, concise, and complete
• Legible
• Thoughtful
• Timely, contemporaneous, and sequential
• Reflective of the nursing process
• Retrievable on a permanent basis in a nursing-specific manner

Nufactor has made the Nursing Visit Notes part of the patients' supplies to ensure correct information is documented for home infusion purposes and returned in a timely manner. The highlighted sections of the guide emphasize the most commonly missed sections of Nufactor Nursing Visit Notes documentation. Nufactor is known and appreciated for the 'vetting' process it has in place, and Nursing Visit Notes are discussed in detail with the nurse prior to the initial patient visit. During this vetting process, nurses are provided with the guide and are instructed on specifics. Clinical changes occur often and must be noted by the nurse. Nufactor maintains electronic versions of completed Nursing Visit Notes, which may be accessed by any accrediting entity or may be provided to the prescribing MD if requested. After The Joint Commission (TJC) conducted our triennial survey, some changes to the Nursing Visit Note were recommended. Nufactor implemented the following in response to Findings/Corrective Action to improve our nursing program:

• Medication Profiles (page 4) - Previous practice was for the field nurse to complete a full medication profile for EVERY visit. Notes such as "no changes," "same," or "see Day 1 of 2" were not permitted. TJC found that medication profiles submitted by nurses frequently did not match the medication profile on record, they found two profiles submitted by two different nurses on two consecutive visits did not match. Nufactor modified the process to include sending a current medication profile with each delivery. The nurse will no longer have to complete a full profile. Instead, the nurse will review the enclosed profile and check the appropriate options in the medication profile section of the Nursing Visit Notes.
• Abbreviations - TJC published a list of prohibited abbreviations several years ago to help avoid administration errors caused by certain abbreviations. The list is on the medication profile section of the Nursing Visit Notes to act as a guide.
• Technique Tips – This is a new section included in the Nursing Visit Notes to remind nurses to follow standard precautions. Standard precautions should be followed in a home the same way they are followed in a clinical setting. For example, gloves must be worn at all times for an IV start. The index finger may not be torn purposefully to allow direct palpation of a vein. Vial stoppers are not sterile and must be wiped with alcohol after removing the lid. Medication additive ports and access device ports must also be wiped with alcohol prior to accessing. Any time alcohol is used, it must be allowed to fully dry, without fanning, wiping, or blowing.

Legibility is also a problem at times. Newer generations are steering away from using pen and paper, which clearly shows down the line. Many would think they would have been destined to become a doctor, with the scribble-scrabble that is seen on notes.

Nufactor contracts with nursing agencies include timely Nursing Visit Notes submission. This practice is not just to micromanage agencies or to be the top dog calling all the shots. Timeliness affects not only reimbursement but proper therapy communication. A nurse must practice due diligence and report an intolerance directly to the pharmacy since the pharmacist depends on the information to make timely recommendations. Although, the majority of Nufactor's Nursing Visit Notes are to be filled out by exception (only document if not within normal limits), the nursing process is able to be fully met if the nurse documents education provided to a patient in a narrative form. Assessment is always to be completed prior to completing an infusion. The diagnosis is provided by the pharmacy to ensure the nurse is aware of what they are specifically providing therapy for. Outcomes and planning are also in a fillable section, including documentation of whether the patient tolerated the infusion or not, and when will the next infusion be scheduled. The infusion log covers the implementation of the nurse's process. That section has actual vital sign parameters for the nurse to follow to ensure the patient is tolerating the medication and specific instructions on how to monitor the patient. In this section, it is imperative that the nurse fills out the amounts and strengths of ALL drugs being used, including heparin and saline. Nufactor has made adjustments with easy-to-use check boxes.

Remember, when a nurse's note is filled out properly, it is very effective at providing the proper information needed to ensure the patient receives safe and effective therapy. Also, let us not forget that nursing notes are legal documents and must be treated as such; proper documentation could make or break you in a courtroom or in front of your peers in a board peer review. Proper documentation is one way of demonstrating the high level of care patients can and do receive in the home setting.