Is it possible to document too much?

neonatal_nurse · Dec 4, 2009

I don't think there is such thing as over documentation. Just as long as everything is objective, factual and needed in the patient's care plan. What your supervisor may be referring to is proper prioritization. You should be able to prioritize your charting according to the patient's case/diagnosis. Like while you may put normal assessments on skin, bowel movements and etc., when should prioritize or focus that the patient is in pain. Therefore, focus your documentation on pain- assessment, management, etc. and you may disregard the rest or place them at the bottom part of your charting. Anything else, maybe you can look up your student notes and review them. In time, this will come naturally to you.

Good Luck!

RNperdiem, RN · Dec 4, 2009

I agree with the above in priorities.

For example, I give highest priorities to vital signs, intake and output, pain and assessment. These things will actually be checked by others and will affect the outcome and orders given.

A lot of the rest of documentation is lesser clerical work.

A patient's recovery has more to do with what we actually do than with what we write about.

ktwlpn, LPN · Dec 4, 2009

Maybe you were adding lots of extraneous details and not using approved abbreviations? I've read notes that sound like a 4th grader speaking " I asked the resident to stand up, the resident said " I can't" The resident was wearing wet navy blue slacks.I attempted to explain to the resident why it was important to stand up because she was wearing wetnavy blue slacks and I wanted to asist her in taking off thoses wet navy blue slacks and putting on clean brown slacks" I'm really not kidding -this is quoted alomst verbatim from a chart at work.

classicdame, MSN, EdD · Dec 4, 2009

I believe you can over-document. Just state the facts and none of the extraneous details or sccial issues (he said-she said stuff). But please do not fail to document changes in condition or anything related to admission diagnosis. I audit charts of COPD pts with no 02 sat ever mentioned by anyone other than Resp Therapist. No mention of lung sounds----but plenty of notes about how complaining the patient is.

floatRN · Dec 4, 2009

I've always wondered..If a patient requests a copy of their medical record from the hospital. Do they get a copy of all our nursing notes? I have seen some nursing notes about difficult patients that the nurse would probably not ever want the patient reading.

1996RN · Dec 4, 2009

i think there is definitely a chance of documenting too much. that is why most hospitals have gone to charting by exception. the more you document, the more lawyers have to pick apart, looking for little things (that can be big in the courtroom) such as spelling errors, punctuation and grammar errors, contradicting yourself, etc.

HmarieD · Dec 4, 2009

I've always wondered..If a patient requests a copy of their medical record from the hospital. Do they get a copy of all our nursing notes? I have seen some nursing notes about difficult patients that the nurse would probably not ever want the patient reading.

You bet. Nurse's notes are an integral part of the medical record.

PurpleLVN · Dec 4, 2009

I believe it depends on the doctor, supervisor, instructor,etc. I had an instructor who wanted down the mountain, in the valley, through the woods documentation!! Most doctors I work for want brief but detailed documentation. Don't be so hard on yourself-just prioritize and give the facts!!! :nurse:

Laughs-a-lot, RN · Dec 4, 2009

As far as that goes, I say save it for report. When charting the note, include what what said, what was done, what was the situation. Do not add any personal feelings to the note. The note can show how annoying and crazy said patient may be even by just stating facts only.

rstrainRN · Dec 4, 2009

I'm inclined to say when in doubt, document. However - coming from a critical care background and doing quality assurance work on charts I can certainly agree that it is absolutely possible to over document.

Here's an example. I work in pediatrics. When a kid is moving or thrashing around or kicking sometimes their pulse ox will not pick up and alarm. You can tell that the pulse ox waveform is not picking up, that the child is upset but still pink and breathing comfortably. We had a nurse who documented that their patients pulse ox desatted to the 60's and then detailed everything they did after that. In reality this was a simple but quick equipment error, the childs pulse ox truly never deviated from normal. The patient was never in any kind of distress. Checking the probe and changing it would have remedied the situation and not required a note of any kind.

Of course for a true desat with the patients color changing or requiring ventilation would necessitate documention and rightfully so. But this was an example of creating something out of nothing.

carachel2 · Dec 4, 2009

You'll never regret over documentation that one time ou are brought in under a sweeping lawsuit and are forced to give a deposition that goes over every.single. minute of patient care you provided. I agree that you need to make sure you are leaving out fluffy details like "pt smiled and turned out her bedside light and drank some water." But you need to be clear and specific and make sure your time lines are accurate; every intervention should have an appropriate follow-up assessment and documentation and every positive exam finding should be explored and addressed.

I've had coworkers make fun of me, but I've learned to provide enough details to reconstruct the story of what I did with that patient and to show I prioritized patient needs and coordinated the proper care to meet those needs. I tell you what though, the deposition was an eye opener (*I* wasn't being named in the case, but they will sweep in and pull everyone whose name was on the chart into the deposition) and I was *very* very thankful that I could pull it all together and reflect what had been brought to me (i.e. a crashing patient) and what I did.