At the end of a long shift, the nurse documents that Mrs. Smith “refused her shower again this morning.” However, if we spoke to Mrs. Smith, we would learn she prefers her showers in the afternoon because mornings are painful due to her arthritis. That single sentence in the chart misses the full picture, along with an opportunity to honor this resident’s voice, dignity, and autonomy.
In long term and post-acute care, where residents often live for extended periods of time, documentation should do more than track clinical tasks. It must tell the resident’s narrative, support informed and tailored care, and reflect the heart of resident-centered practice. Simply put, documentation goes beyond the chart. Rather, it’s a reflection of the resident’s care journey.
Read more at https://www.providermagazine.com/Pages/Resident-Centered-Documentation-Is-More-Than-a-Chart.aspx