Documentation Toolkit for the Nurse Leader

The adage nurses are repeatedly told, “If it wasn’t documented, it wasn’t done,” which acts as a mantra to remind nurses of why they should document. Despite knowing the critical purposes documentation serves and repeated reminders to document, clinical nurse teams in skilled nursing facilities still struggle to consistently capture documentation that is timely, accurate, and comprehensive. 

With AADNS’s Documentation Toolkit for the Nurse Leader, directors of nursing, staff development coordinators, and other nurse leaders will use this set of tools and resources to systematically apply the four pillars of documentation - the nursing process, skills and competency, clinical leadership, and organizational management - and make lasting improvements to documentation in their facility.  The tools and resources in this toolkit are designed by nurse experts to be practical, applicable, and include fun educational activities specifically for the nursing team. 

Put this toolkit to work for your team today!

  • Use the 40 educational tools, which includes 19 different documentation guides covering clinical conditions and special situations, to enhance the nursing team’s ability to apply the nursing process and document accordingly
  • Create workflows that enable documentation to occur consistently and enhance the quality and comprehensiveness of documentation using various methods of clinical leadership
  • Apply the relationship between the nursing process and documentation as a framework to develop competency of documentation skills
  • Define documentation standards as they relate to the requirements in the Medicare Benefit Policy Manual
  • Understand the relationship and processes involved between documentation in the medical record and the MDS, with emphasis on Payment Driven Payment Model (PDPM)
  • Learn the documentation protocols that can mitigate the risks of litigation
  • Find out how surveyors utilize the documentation in the medical record to investigate compliance with regulations

Preview the table of contents and excerpt from the Documentation Toolkit for the Nurse Leader.