Work Not Documented Is Work Not Done
July 22nd, 2011
By Jennifer Olin, BSN, RN
Document, document, document…it is a word and a phrase you will be subjected to repeatedly during your nursing education. Whether in a traditional school or attending classes online, nursing documentation is a central component in every area of this profession, and every nursing instructor will drive that home.
The Joint Commission says that nursing data related to assessments, nursing diagnoses or client needs, interventions and outcomes must be permanently filed in a client information system. Whether an EMR (electronic medical record) or a traditional paper chart, every healthcare organization has policies about recording and reporting client data, and each nurse is accountable for practicing according to these standards.
Records of a patient's healthcare journey are kept in doctor's offices and clinics, hospitals and half-way houses. The notations come from nurses and physicians, social workers and physical therapists, dieticians and pharmacists, and the data is used for any number of purposes.
- Planning Care: Each health professional involved with patient care formulates their plans with information in the medical record. Nursing data is used by the physicians to order a specific antibiotic after receiving lab results and seeing the nurses' notes of the patient's continuing fever. Data from the dietician helps the nurse reinforce necessary dietary changes. The connections go on and on.
- Communication: The record is the way the different healthcare providers communicate with each other. This prevents delays in patient care.
- Legal Documentation: The record is a legal document and is admissible in court as evidence.
- Research and Statistics: In teaching institutions and even private facilities, the information contained in the medical record can be a valuable source of data for research. The treatment plans of patients who share a specific disease process can yield information helpful in treating others or finding a cure.
- Education: Students in many healthcare disciplines use client records for comprehensive views of the illness, treatment strategies involved, and other factors that affected the patient's progress and recovery.
- Quality Assurance: During audits, a patient's record is used to monitor the care the patient received and the competence of the people delivering that care. For example, during a nursing audit, the nursing interventions are monitored and measured against established standards.
- Accrediting and Licensing: Organizations like The Joint Commission review clinical records of clients to ensure the facility is meeting national standards.
- Reimbursement: Documentation is how a facility gets paid, by the federal government. For a hospital to receive Medicare payments, the patient's clinical record must contain the correct diagnostic related group (DRG) codes and reveal that the appropriate care was given.
Charting Dos and Don'ts
As stated in the title, work not documented is work not done. The time and place of a bed bath may not be essential information in a patient's hospital record; however, almost everything else, including when, what and how medications were given, the location of the IV and even the nurse's observations of the patient's emotional state need to be properly recorded. Information needs to be accurate (including spelling and grammar), appropriate (information that has no bearing on healthcare should not be included and could be considered an invasion of privacy) and it should be brief (get to the point).
Nurses and everyone else charting in the medical record need to use standard terminology, watch abbreviations (fewer and fewer are acceptable) and if in doubt, write it out. JCAHO has a list of unacceptable abbreviations and so do most healthcare facilities.
Most notes will follow a certain format. For example, when documenting a nursing procedure, include:
- What procedure was performed
- When was it performed
- Who performed the procedure
- How it was performed
- How well the client tolerated the procedure
- Any adverse reactions to the procedure
Other Tips and Suggestions
Proper charting and training takes up chapters and hours of every nurse's education. There will always be corrections to be made, or information to be added, but it is all actually vital. Also, no one wants to jeopardize their license and their livelihood for simply forgetting to write something down or type it into the EMR. Some of the most dangerous mistakes can be prevented by very simple means.
- Make sure you have the correct patient's chart. Check the spelling of the name and the medical record number and the birth date and whatever else you can think of before starting to chart. Writing an order for wrong patient or giving the wrong medication can have dire consequences.
- If hand writing, write legibly, print if you have to. Do not let mistakes happen because someone else couldn't read what you wrote.
- Chart as soon as possible after completing the task, try not to wait until the end of the day, information gets forgotten.
- If you don't give a medication circle the time and document the reason for omission. Not giving a medication can be as important as giving the right one.
- Do not chart opinions. Do not use language that suggests a negative attitude towards the client, and do not chart what someone else said, heard, felt or smelled unless the information is critical. Make sure to assign credit to the individual who said it.
There are dozens of other little rules, tips, comments, do's and don'ts and they are as individual as each institution. As a new nurse, you will be trained in that facility's style and it is best to stick with their plan. Charting is not a place for individuality; it is a place for standardization.
Here is one final, very important note: Charting care you have not provided is considered fraud. It is as bad, or worse, than not charting at all. Either way, improper documentation is not worth losing your license over.
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