It is taught in nursing school. It is heard in a court of law. It is heard during your performance evaluation. It is not part of policy stated directly as such but to not document can be a violation of company policy--"Failure to document" is a policy violation but is simply worded differently at each institution. It is a legal liability issue.
If you did a nursing procedure (gave a medication, gave a bath, changed a dressing, took and implemented a verbal order) but did not document it in the nurse's note, you cannot prove that you actually DID it. In a court of law or in a chart review process, there is no record that it was done THEREFORE--it was not done. NOT DOCUMENTED, NOT DONE.
Originally posted by kmahoneyrn Was this taught to you in nuring school, in clinical practice or it is a part of your policy manual, or all three?
All three! Even something that seems simple, that in and of itself probably doesn't need to be charted, you have to look at it in the long run. IF something bad happens, would this info be helpful?
If an incision looks weird, and I'm in the room when the docs looks at it, and I say I'm concerned about the way it looks but he doesn't think it's anything bad. I chart that. "MD at bedside, aware of above described appearance of incision. No orders received" Then, if that thing rips open, the doc can't say "I had no idea it looked bad"
one thing l like about the er is that the documentation is lighter than floor nursing. however......l probably do more documenting than most of my co-workers. l try to make it a point to document at least 1 or two insignificant things, like.....pt given blanket on request etc, it shows interaction with the patient...they can't claim later that no one came in their room for 3 hours to check on them. l always document safety issues, siderails up, call light in place etc. l am shock at how many of my co-workers don't think this is important. also, since we get a lot of drug seeking, l document pt behaviors....calm alert affect, laughing and talking with visitors, talking on phone etc......l know of a nurse that was given a 1000.00 reward from a hosp. because she documented.."visitor walking in hallway with a tall long neck bottle in a paper bag." turns out this person fell and tried to sue the hosp, unsuccessful due in large part to nurses doc. documentation is your best friend!!!!!
At the end of the day when you have documentation scrutinised by people with no or little medical knowledge, how can we expect them to apreciate any evaluation, intervention or observation unless its documented.
I have a good example of "not charted not done"...a facility I know of had a lady that passed away, before hand she had decubs on heels. Several months after her death the state came and did their annual eval, they pulled this woman's file and said the decubs could have been prevented. The tx nurse told them everthing was done possible and she was noncompliant...state said "it was documented anywhere" and the facility received a fine. So ALWAYS ALWAYS ALWAYS DOCUMENT DOCUMENT DOCUMENT!
yep make the lawyers happy or else...you may not have a license (sigh)....even if YOU ARE A GREAT NURSE if you did not document it, it just did not happen. such is life in the litigious environment in which we practice and live today. don't get me wrong...true malpractice MUST BE STOPPED ....."do no harm" is what I live by....but to prove it, it must be on paper. (or in the puter).....
Originally posted by kmahoneyrn i am looking for a respnce to the statment 'Not documented, not done." Was this taught to you in nuring school, in clinical practice or it is a part of your policy manual, or all three?
Yes, this was definitely STRONGLY stressed in nursing school through teaching and reinforcing in the clinical area when documenting notes in patients charts. If it wasn't charted, it wasn't done - when a lawyer gets a hold of a chart especially, so chart what you do for a patient to protect and cover yourself, and your nursing license.