Is it possible to document too much?

[Spritenurse1210]

In a recent evaluation by my supervisor at my last job, she told me that I tend to over document. She went on to further elaborate that over documenting is just as bad as not documenting at all. Can anyone offer me any constructive feedback as to how to document properly without over doing it, or help me find an online documentation course so I can improve?

[TheCommuter, BSN, RN]

State surveyors arrived at my former workplace a couple of years ago for a full-book survey of the place. While reviewing charts, someone's bizarre documentation captured their attention:

"Pt. self-propels W/C to kitchen and asks for utensils. Dietary staff hands pt. plastic utensils wrapped inside napkin. Pt. proceeds to consume 100% of lunch."

The state surveyors issued a deficiency to the facility due to this unnecessary charting because they deemed that plastic utensils were unsafe for patients. They also felt that dietary should have delivered the utensils to the patient on the meal tray, and that the patient never should have had to come to dietary to obtain them.

While the state surveyors had valid points, the nurse charted too much extraneous information that got the facility into some trouble. The only thing that truly needed to be documented was, "Pt. feeds self & hydrates per self. Consumed 100% of meal."

[HeartsOpenWide, RN]

I am a new nurse. I have been told you can hang yourself on over documentation. Documentation should be sweet and to the point. No need to have diarrhea of the pen. I trained with a very good nurse that documented more than her coworkers and said that there was nothing wrong with it as long as it is pertinent and to the point and no fluff.

[BigBub1000]

The wet pants client above could be said like this -

1115 Client incontinent, slacks wet; she refuses changing now and is combative when writer attempted to remove wet pants; will try again shortly;

You've stated the problem, the attempt to correct, why you were unable to correct it, and what you plan to do about it; No one cares if they were blue or brown or all the rigamarole involved;

1145 client allowed perineal washing & clean slacks were put on now; skin intact, no redness/lesions; resting in her chair now, calm;

Keep it brief and factual.

1004 paged Dr. Jones at 909-0444 re: VS 188/144 98-18-96.9-80%; placed on 02 2l/nc, sitting up in bed, c/o hard to breathe if not upright; diaphoretic; A&Ox3, denies CP, headache, any other pain or discomfort; dtr Susan says "Please get Dr. Jones now."; Dr. Jones was overhead paged at 1003 and his office was called at 1003 phone # [phone], office manager "Ellen, RN" made aware of client's VS, dyspnea, and dtr's request that Dr. Jones come now to see patient, she agrees to continue paging Dr. Jones until she reaches him and will send him to client stat, upon reaching him;

1007 Charge Nurse with patient; 198/150 99-24-80%; Rapid Response Team called at 1006 and arriving now;

See? brief, factual, emotionless; dtr was not screaming or demanding or terrified to within an inch of her life, she only said to please get Mom's doc now. You are not cursing the invisible, unreachable doc, you stated what you had done to get him. When you couldn't get him, you got the Charge Nurse and the RRT; You've got it under control. You are scared, nervous, frustrated, worried about your other patients who are being neglected while you handle this problem, you need to pee, you are starving, your own child is home sick, and your gal who picks up your son at school has canceled and you haven't had time to make alternative arrangements yet. But that should not be and is not reflected in the chart. The fact that your other coworker refused to help you while she polished her nails is left out.

And I agree with the maxim of the less said the better in so many cases.

[Yakuza77]

Use your own judgement in determining whats relevant to document. Try to be succint and to the point

[kanzi monkey]

Less is more. Sometimes we document more than is needed when we feel unsure of what NEEDS to be documented. I definitely have this problem. I think I usually get the main point in there, but I sometime look at my documentation and wish I could remove half of it. There's nothing worse than starting a sentence that you can't finish. I consider myself a good writer--but I'm actually just an extremely good editor, a skill that isn't very useful when you're essentially writing on legal documents all day.

One piece of advice--when I have a particularly difficult patient, or a scenario where I have formed judgments about my patient or a family member (I do have them sometimes), I pretend that they WILL read all of my flowsheets and notes--likely in a courtroom setting. While my notes may occasionally be disorganized or rambling, they never contain loaded or emotional words or phrases.

[KneKno]

I was told by an English instructor: Writing should be like a miniskirt--Short enough to capture interest, long enough to cover the material.

I think overdocumentation can occur, especially if double charting. I have a flowsheet to document IV rates. If I'm making changes in rates, I put it on that flowsheet, not in my notes. (I will put "Titrating name of drug for whatever reason"). I don't want a discrepancy in times or rates between my notes and the IV flowsheet. I also see lots of nurses re-charting a lot of information that's in a physical assessment flowsheet. I've read thru notes that have, in narrative form, the exact same thing that's covered on the flowsheet. I don't feel like I have enough time to chart it all once, let alone twice.

[caliotter3]

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

I work in home health. Clients who copy the medical records for future use in their lawsuits as well as just having a copy that they did not pay for, look for the juicy stuff that the nurses write. They may have the gall to grill you about items in the nurses notes. On one case, the primary nurse acted as an accessory by doing the record copying for the family. I always wondered what the agency thought of her behavior. The first nurse who told me about this also told me that was why most of the time the nurses focused on what the patient was watching on TV. Now that is what I call defensive documentation!

[caliotter3]

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.

I was really embarassed when a family member described just such a situation to me. Don't think for one minute that all clients are uninformed enough not to know the difference between a true desat and a short-timespan equipment glitch remedied by repositioning!

[Ruby Vee, BSN]

i once worked with a nurse whose notes reflected quite a bit of his personal opinions, but the one that got him reprimanded said something to the effect of "dr. imanidiot notified of patient condition described above and of this writer's suggestion that he take patient back to the or for bleeding. despite all of the above noted reasons for the suggestion, dr. imanidiot declined to take patient to or. given the moronic nature of dr. imanidiot's thought process, this writer has paged dr. imandiot's boss to come straighten him out."

ok, i've gotten a few words wrong (including the actual doctor's name) -- but that was the actual note, to the best of my recollection.

the op wasn't charting anything like that, was she/he?

[~Mi Vida Loca~RN, ASN, RN]

I was told by an English instructor: Writing should be like a miniskirt--Short enough to capture interest, long enough to cover the material.

HAHAHA Love it!

[nursel56]

The narrative portion of our flow sheets are short for a reason!! That doesn't stop some nurses from writing itty bitty printing, squeezing 2 or 3 lines into the space for one and traveling up the margins toward the top of the paper. Somebody once drew a couple of little clocks with arrows pointing to god-knows-what, she changed the time of something, I think, but I really can't be sure.