If you didn't document, you didn't do it!
Documentation is a minefield that we have to tread very carefully. One wrong step and it could blow up in our face. Computer charting has simplified our process. The little check boxes allow us to say if we did or didn't do a certain task. It is easy but how many of us really document everything we do?
Documentation and the average nurse is a hot topic, so you have to start as you mean to go on!
Documentation in nursing varies a great deal, what you should document, what you do document and what you don't document.
Documentation is a minefield. We have to tread very carefully because one wrong step and it could all blow up in our face.
Have you noticed in the health care field, it is nearly always the nurse that the buck stops at?
Question is this because we have the most to do and the least amount of time to document?
How many of us have to justify staying over to document? How many of us then have a discussion about time management skills?
How many of us really document everything we do? Computer charting has certainly made it a lot easier to do for the everyday things we do religiously. The little check boxes, allow us to say if we did or didn't do a certain task.
Quick and easy, you might think? Yes but it is still time consuming and several pages long, little check marks do get missed and they could be vital when neglect is brought up in the 'court of law'.
You know that 'sods law' dictates that things always seem to happen to the same patient. So if it was missed being checked once, you can bet your bottom dollar it is missed time and again.
Always, Always document the abnormal, this is what the auditors of our documentation are looking for, especially in a patient who has a compromised care, or the family are pointing fingers, either fairly or unfairly.
Written documentation of the abnormal will support your case, and ensure that following professionals can see what has occurred.
It honestly doesn't matter if you are the best nurse in the world, if your documentation doesn't support this, then your job could be in jeopardy.
You owe good documentation to the safety of your patient and to protect your own self.
Remember and I have said this before if you didn't document it you didn't do it! Take these word and write them on your heart, because as cruel and as harsh you think the words are, the reality is so much harsher if you didn't document.
When I trained as a nurse it was all paper documentation, we were taught to document the rationale behind the abnormal for example:
A patient has a 'new' elevated temp, so what did you do for it? You can't just say a patient has an elevated temp. You would have to say patient has elevated temperature, blood cultures drawn as per doctors' orders, Dr informed antibiotics commenced, Tylenol given. Review in 1 hour.
What happens in reality is we find the patients has a temp, so we review charts to see if this is normal for the patient, consider the patients diagnoses, call the doctor, take the orders, fax the pharmacy, start the meds and so on.....Not a quick fix, could possible take an hour to get everything sorted. In the meantime your other patients also need attending to.
So we go to document at the end of the evening because in truth we just haven't had the time to document before. Then we will fluff over the details of what we actually did because we are tired and due to all the intensity of the day that temp may have been a minor event.
Of course this is the minor event which comes back and bites you in the ...............
My recommendations to you all is
1/ Try to document as soon as you can, get yourself into routine
2/ If you just can't find the time to document, then scribble some notes and key words down to jog your memory
3/ Write clearly, so not only can you read and understand but anybody else following you understands
4/ Always document the abnormal, and document what you did about it.
5/ Document verbal conversations with other healthcare professionals
6/ Time stamp everything, if you can't get to the computer to document. Jot down a time you called a Doctor or the time he called back, and make sure this is included in the official charts
7/ Keep it simple
8/ Try to formulate a pattern you can follow, when you do a head to toe on a patient you follow a routine. Make your documentation follow a routine.
9/ Do not throw other staff members under the bus in your documentation. Document only what you did, not what you think somebody else didn't.
10/ Always remember if you didn't document you didn't do it!Last edit by Joe V on Nov 9, '12
About madwife2002, BSN, RN
Joined: Jan '05; Posts: 10,272; Likes: 6,111
Director of Nursing Services
26 year(s) of experience in RN, BSN, CHDNNov 9, '12Amen, thank you, thank you, thank you!!! I work in home health, my client receives 20 hours of skilled nursing care a day, a nurse always follows me, but I come on after the break and rely on report from the family and the nursing notes from the nurse ahead of me. OMG, some of them are atrocious!!! Mom told me last night that the day nurse suctioned the trach at least 6 times. Good thing she told me b/c the day nurse didn't note it even once!! Same thing happened a few weeks ago, client had been pretty ill (for him), fever, increased HR, poor O2 sats, etc. I'm reading the notes to track how he's doing and responding to interventions, no assessment or vitals noted on the paperwork! I asked family about it and she says "I know she did it, I saw her taking his temp". The next time I worked those vitals were miracuously in the area on the flow sheet. UGH!!Nov 9, '12Well said. I am just a student Nurse. I have't even started(just got accepted to start Jan. ) However..... prior to being a student nurse I worked in a hospital HR office. I was the one who the Nurse Managers/Exec. came to when they wanted to discipline (i.e. fire) a nurse. For RN's, by far the number one reason for involuntary separation was poor/lack of documentation. (For CNA's it was sleeping on the job).
Not only is proper documentation incredibly important, it is easy to "document" poor documentation. Blank, incomplete, or incorrect charts were my constant companion as I examined the evidence of poor work performance. I would do employee orientation twice a month and every time I would say that the three most important things in working in a hospital are "documentation, documentation and documentation."Nov 9, '12Documentation is SO important. Document every intervention, every encounter, every time you call/speak with the doc and document what they say verbatim. Document your suggestions and what you report. I'm in awe at how LITTLE some of the nurses at my facility document. They tell me of all of these interventions that were done and all of these calls that were made to the doctor but nothing ever gets documented. Get in the habit of rechecking your charting to make sure you did everything.
Must Read Topics