Documentation is one of the most critical skills nurses perform, regardless of the setting in which they practice. Accurate, detailed charting provides a clinical picture of the patient and a chronological history of their health care. Nursing documentation enables effective continuity of care for the patient. It also provides legal protection for the nurse and their employer. Nursing documentation provides important information for Continuous Quality Improvement projects and audits, and provides information about the care given at the facility to such accrediting bodies as the National Commission on Correctional Health Care and the American Correctional Association. Always remember that what is charted today may be read in the future by many people, including other team members who care for the patient; accreditation, certification, and licensing organizations; performance improvement committee members; and lawyers and judges if the incarcerated person’s medical record becomes part of a legal action.

Purposes of Documentation

The main reason for the health record is to facilitate continuity of care for the patient and to communicate pertinent information about the patient. This includes the condition of the patient, what was done for the patient, and how they responded. As a nurse, you are responsible and accountable for your own practice, and documentation is part of that accountability. In the event of legal action, the health record will be a primary source of information regarding what the healthcare providers did or did not do for the patient. The nursing care provided will be evaluated based upon what is written in the health record, and so it is crucial that the “who, what, when, where and why” of all the care provided (and omitted) to the patient is recorded.

Documentation of the details is imperative to good charting. Specific information that presents a picture of the patient, as they presented to you when you rendered care, is important. The specific care that you provided is also very important to document, as it may be evaluated against accepted standards of nursing care. The patient’s response must be documented, and, if the care rendered did not address the patient’s problem as expected, the additional nursing interventions, done or planned, must also be documented. As you document, consider that you may have to use your entries years in the future to validate your assessment of the patient and the appropriateness of your patient care. Be concise, but thorough.

Standards of Nursing Documentation

There are state and national organizations that set standards for nursing documentation practices, and typically healthcare organizations base their policies and procedures concerning documentation on these standards.  They include the following organizations:

• Centers for Medicare and Medicaid Services, Conditions of Participation
• The Joint Commission National Patient Safety Goals Conditions for Accreditation Manual – Hospital
• American Nurses Association
• Nursing Specialty Organizations
• State Nurse Practice Acts

Regardless of which organization’s standards chosen, all sources of documentation standards emphasize the following important-to-document components of nursing care:

Relevant statements made by the patient

Ongoing assessment of the patient and his/her condition

Patient teaching, including the patient’s response to teaching and indication that

the patient has learned

Patient response to all medications, treatments, and interventions

Nursing documentation should be

• Accessible
• Accurate, relevant, and consistent
• Able to be audited easily
• Clear, concise, and complete
• Legible/readable (including the resolution and related qualities of EHR content as it is displayed on the screens of various devices)
• Thoughtful
• Timely, contemporaneous, and sequential
• Reflective of the nursing process
• Retrievable on a permanent basis in a nursing-specific manner

This post based on The Correctional Nurse Educator class entitled Documentation for the correctional Nurse. What are your thoughts about the standards of documentation?