If you are a registered nurse who dreads documenting the care you provide to patients—you are not alone. Many nurses dread documentation because it takes them away from patient care but proper documentation can help nurses avoid medication errors and legal troubles.
With new legislation designed to protect people receiving medical care being enacted on a continual basis, there is no better time than the present to review the do’s and don’ts of nursing documentation.
I’m sure you’ve heard the phrase, “If it wasn’t documented it wasn’t done.” This is because documentation is evidence that the patient received proper care.
Documentation allows you to demonstrate how you provided the patient with a standard of care that meets the institutional and board standards in the state where you practice. This article highlights the dos and dont’s of nursing documentation.
Documenting for Practice and Liability
Did you know that the medical record might be the only evidence presented in a lawsuit? This is because the patient’s medical record is the most powerful tool attorneys, legal experts, and expert witnesses use to examine the type of care the patient received from the health care provider.
As nurses, we know that failure to provide timely, accurate documentation is unsafe, irresponsible nursing care. This is true even when we are caring for highly acute patients in an understaffed setting.
If care was provided that wasn’t documented in a timely manner, the failure to document the care could put a patient at risk for getting a double dose of a medication(s), unnecessary treatments, or a discontinuity in medical care.
When you assume care for a patient, you are in essence saying that you will provide the patient with a standard of nursing care. If it is determined by the court that you breached your duty by not providing the patient with the standard of care recognized by the state in which you practice, then you could be liable for damages and end up losing the nursing license you worked so hard to achieve. This is why it’s important to brush up on the dos and dont’s of documentation.
Documentation Red Flags
Attorneys have a knack for finding red flags in documentation records. For example, they scan written records or electronic medical records for errors in documentation. Here are some of the red flags they look for in both written and electronic patient records so you can avoid documenting errors.
When Documenting Don’t
- Write illegibly. The judge or jury can interpret messy writing as a reflection of messy practice.
- Use uncommon abbreviations. Avoid abbreviations that are non-medical and never add texting language in patient records.
- Include subjective data. For example, refrain from documenting judgments you make about a patient like ‘He is an angry old man,’ ‘She is irresponsible and rude,’ or ‘She’s a spoiled little brat.’ Keep the documentation objective.
- Leave large sections of time blank. Remember if it wasn’t documented it wasn’t done!
- Don’t add in late entries. Try to squeeze in or add a late entry to the patient’s record to look as if it was documented on time.
- Failure to document a change. It’s extremely important that you document any change in patient or family status that occurs during your shift.
- Never document adverse events. Refrain from documenting in the patient’s chart that an adverse event report was completed.
- Erase or use different colored ink. Don’t use different colored ink, erase, or try to write over an entry. Although most facilities have electronic records, many places still have some handwritten documentation records. It’s important that you continue to employ the handwritten standards of proper documentation.
- Include meaningless jargon. Avoid long unspecific notes. Instead stick to the basics and make the entry concise.
Now that you are aware of some of the documentation dont’s let’s focus on the documentation dos. As you work to improve your documentation skills and form a positive attitude about the importance of documentation, the quality of patient care you provide will also improve.
When Documenting Do
- Use objective data. If a patient refused his medications document exactly what occurred in the chart. For example, you could document the following: “After giving the patient his oral medications he threw the medications on the floor and said, ‘I refuse to take this poison!’”
- Include the following: Date, time, your title, and your full name with your signature in every entry.
- Follow the standards of care. Document how you provided care according to the standards of care outlined by the state and facility where you practice.
- Include nursing interventions. Add the interventions you provided and the patient’s response to the treatment.
- Include any patient refusals. If a patient refused treatment, document the incident. Include the patient’s verbal and non-verbal response using as much objective detail as possible.
- Include follow up care. Document how you followed up a medical situation with the appropriate patient care. For example, if the patient’s status changed and you notified the physician, document the change in patient status and that you notified the physician. Be sure to include the changes the physician made and the patient’s response to those changes.
- Make documentation a continuing, ongoing process. Do not leave large spaces of time in the patient’s chart. Although you may know that you were there observing the patient, the court only has the patient’s medical record to go by and a blank area in the patient’s chart can be interpreted as a breach of duty.
- Document the discharge teaching. Include in the chart how the patient demonstrated an understanding of the discharge plan.
- Include what care you delegated. Document what you delegated to other staff members and when that care was provided. This demonstrates that you made sure the duties you delegated to the staff were provided to the patient in a timely manner.
- Chart according to you five senses. Include terms like ‘I palpated a pea size lump,’ ‘I observed a yellow tint to the skin,’ ‘Skin was hot to touch,’ ‘Crackles were heard upon auscultation of the lower lungs,’ or ‘Urine was dark amber in color with a strong rancid odor’ in the patient’s chart.
- Include any objections. Document in the patient’s chart any treatment plans or interventions that you objected to and how the situation was handled.
Good documentation is an important part of improving both patient care and nursing practice. Proper documentation promotes safe patient care, good communication among staff members, and the advancement of the nursing profession.
To find out more about the specific documentation standards where you practice, contact your state board of nursing.
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