Keying in on documentation

Karen L. McDonald, RN, BSN, of KLM & Associates, LTC Consulting, LLC, offered nurses tips, tricks and good advice on keeping accurate and consistent information while speaking at the 2011 National Association Directors of Nursing Administration conference in Kissimmee, Florida.

Today, there are three general types of documentation: narrative, checklist/template and electronic, McDonald said. I was surprised to learn that only around one-third of the country’s more than 15,000 SNFs use electronic health records for documentation at this time.

The importance and diligence required to maintain consistency in documentation pays off during audits and is beneficial in cases of litigation. To be consistent, McDonald stressed the need for staff education and establishing a list of standard abbreviations to be used facility-wide. This prevents staff from using their own personal shorthand to complete documentation.

She cited this example: “FTD.” Do you know what it means? “Well,” said McDonald, “it means fixin’ to die.” Documentation like that just won’t work.

In an amusing, yet provocative exercise, her audience was put through a couple of memory drills, with surprising results. Give someone 15 words in 15 seconds and see how many they can recall in 15 seconds time. It’s not as easy as you think, as attendees soon realized.

Handouts for this and other education sessions are available at

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