Nurses have often heard “if it wasn’t documented, it wasn’t done,” but they still struggle to consistently capture documentation that is timely, accurate, and comprehensive. This struggle sometimes emerges when underlying system failures go unaddressed by leadership. To fix this, the director of nursing services (DNS) and other nurse leaders need to improve the processes that are interfering with sound documentation practices and provide education that links a nurse’s skills to the documentation.
To accomplish these goals, the American Association of Directors of Nursing Services (AADNS) recently published the Documentation Toolkit for the Nurse Leader, which contains several helpful tools and resources to make lasting improvements to nursing documentation. Alexis Roam, MSN, RN-BC, DNS-CT, QCP, curriculum development specialist for AADNS, shares some tips for how DNSs and other nurse leaders can use this tool to review their processes and overcome documentation pitfalls.
Revisit the four pillars of documentation