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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. 

Defining Resident-Centered Documentation

Resident-centered documentation records information in a way that reflects the individual’s preferences, goals, routines, and identity. It moves beyond generic or clinical-only language and embraces details that help the care team understand the person, not just the diagnosis.

Whereas traditional documentation might have focused on what was done for the resident, resident-centered documentation focuses on what matters to the resident. The Centers for Medicare & Medicaid Services (CMS) supports this approach that emphasizes person-centered care in guidance related to care planning, trauma-informed care, and quality improvement. 

Understanding Resident-Centered Importance

Resident-centered documentation has practical, clinical, and regulatory benefits. Facilities should make it a top priority for these reasons:

1.    Improves quality of care.
When documentation describes personal preferences, care plans become more relevant and are more likely to be carried out. Knowing that some residents prefer meals in their room or they find showers overstimulating, for example, helps the team align care with comfort and collaboration. 
2.    Supports resident dignity and autonomy.
Residents are more than recipients of care. They are decision-makers, storytellers, and individuals with histories and desires. Reflecting their voice in the clinical record reinforces each person’s vital role in the care process.
3.    Strengthens interdisciplinary care.
Documentation that emphasizes the social, emotional, and behavioral context allows the whole interdisciplinary team—nurses, certified nursing assistants (CNAs), therapists, and social workers—to collaborate more effectively. It creates a shared perception of the resident. 
4.    Aids in compliance and survey readiness.
Surveyors are increasingly focused on whether care plans reflect resident input and individualized care. Accurate resident-driven documentation is a fundamental way to comply with F-Tags related to person-centered care (e.g., F656, F675, and F699).

Common Barriers to Implementation

Despite its importance, unfortunately resident-centered documentation is not always the norm. Several barriers can get in the way.

Barrier 1: Time constraints
Challenge: Increased workloads and staffing shortages often lead to brief task-oriented entries.
Solution: Introduce charting prompts or templates for resident-centered notes that can be completed in less than 30 seconds. This helps staff quickly add meaningful context without feeling overburdened. For example, “This shift, the resident enjoyed . . .”

Barrier 2: Copy-and-paste culture
Challenge: Repetition across notes may save time but can eliminate nuance and individuality.
Solution: Set a standard that at least one personal update must be included per shift (e.g., mood, preference, goal, or interaction).

Barrier 3: Limited training
Challenge: Many staff have not learned how to write meaningful narrative notes.
Solution: Provide monthly “Smart Chart” micro trainings that are completed in 10 to 15 minutes. 

Barrier 4: Restrictive electronic health record (EHR) systems
Challenge: Templates may prioritize checkboxes over free-text sections that encourage a more detailed narrative.
Solution: Collaborate with your electronic health record (EHR) vendor or IT to add customizable fields (e.g., “Resident Preferences,” “Resident Voice,” or “What Mattered Most This Shift.”)

Putting Concepts into Practice

Creating a culture of resident-centered documentation requires intentional action. Here are some helpful strategies that facilities can adopt:
1.    Incorporate the resident’s voice.
Use direct quotes or paraphrased language that express what the resident thinks or feels. For example, “Mr. Sanchez shared that he prefers to nap before lunch because it helps him feel more alert during therapy in the afternoon.”
2.    Customize documentation.
Work with your EHR vendor or internal IT team to build prompts into templates for individual routines, communication preferences, or cultural considerations. 
3.    Train staff to reframe language.
Help nurses and CNAs move from judgment-based language (“noncompliant,” “refused care”) to language that recognizes a resident’s action (“resident declined due to fatigue,” “resident expressed a preference for care at a later time”).
4.    Involve CNAs and frontline staff.
CNAs often have the most consistent contact with residents and helpful insights. Create processes to capture and value their observations.

Practical Steps for Leaders Today

To build momentum without overwhelming staff, administrators and nurse leaders can use these suggestions to encourage resident-centered documentation in the next 30 days:

• Audit 10 randomly selected notes. Check documentation for personal details or preferences. Share in team huddles some anonymized examples of resident-centered documentation to reinforce good practice.
• Update shift report prompts. Include a reminder to share one resident-centered detail (e.g., “What did the resident enjoy today?”)
• Host a 15-minute in-service. Offer examples of how to rephrase task-based language into resident-centered language.
• Add a “Resident Voice” field in the EHR. Even a small text box labeled “Resident Priority” can help shift a mindset.
• Recognize notable examples. Create a “Storyteller Spotlight” where staff are recognized for narrative notes that capture the whole person.

Link to Quality Goals and the Future

Resident-centered documentation does not just help residents. It also supports broader organizational goals:

• Quality Measures: High-quality documentation can help facilities understand patterns related to falls, weight loss, or behavioral symptoms, leading to more targeted interventions.
• Trauma-Informed Care: Knowing what triggers anxiety or distress in a resident is critical to avoiding re-traumatization. Including that information as part of the record can increase compliance and cut down on refusals of care.
• Equity and Inclusion: Cultural, religious, and identity-based preferences must be documented and honored to ensure equitable care. 
• Technology Integration: Look ahead. Artificial intelligence (AI) and natural language processing (NLP) tools may be able to scan documentation and detect whether notes are person-centered. That innovation will depend on having in-depth descriptive data.

Telling the Whole Story

The next time staff review a resident’s chart, they need to ask themselves, “Does this reflect who the resident is or just what they did?” The chart should assist any team member—whether they’ve been there for a day or a decade—to walk into the resident’s room and know what matters most to them.

Resident-centered documentation is more than best practice. It shows respect in action. When staff write with empathy and precision, they do not just document care, they honor the person receiving it. 

Lauren Stenson, MSN, RN, CNDLTC, QCP, DNS-CT, is curriculum development specialist at the American Association of Post-Acute Care Nursing (AAPACN).