ELEMENTS OF GOOD DOCUMENTATION

Write legibly

Since the patient’s health record is the main method by which information about the patient is conveyed to all members of the healthcare team, it is vitally important that all notes can be read by all caregivers. Errors may be made if the record cannot be read. Lawyers have been known to infer that sloppiness in handwriting equates to sloppiness and indifference in patient care, which caused the adverse outcome for the patient. This may be less of an issue today with more facilities using electronic medical records, but legibility in all things written is still very import

Sign every entry

The nurse’s name and credentials should be written after each entry in the Health Record. It is usual and customary for the nurse’s signature to contain the first letter of the first name, the full last name and credentials, but facility policy will dictate how your notes are signed. If there is no facility policy, your signature should reflect your name as it is written on your license.

Do not leave empty space between your note and your signature

If your note ends in the middle of a line, sign it at the end of the line, then draw a line through the “blank space” until it reaches your name. There should be no place where anyone (even you!) can add something to your note. If you realize that you have forgotten an important piece of information, add another short “addendum” note. NEVER add-on to a previous note. Most electronic health records will allow you to “append” a note, and that is fine as it clearly states the date and time of the additional information.

Spelling and grammar count

Just as illegibility creates a poor impression of nursing care, so, too, does misspelled words and lack of proper medical terms to describe conditions or care given. Use a dictionary or have a list of common spelling errors readily available as a reference. Use appropriate, facility authorized abbreviations. If your facility does not have a list of accepted abbreviations for use by healthcare staff, look online and find one from a reputable organization that your staff agree to use, and use it.

Document as soon as possible after the observation or interaction

Waiting to document unil the end of the shift often results in inaccuracy and recording fewer details, as nurses are rushed and have many details for all of their patients on their mind. However, DO NOT DOCUMENT CARE UNTIL IT IS COMPLETED, as things may change between the time you plan to do something and you actually get to do it.

Document specific times, not a shift (i.e., 0800 hours versus ‘0700-1530’)

It is extremely important that the specific time an interaction, intervention or change in the patient’s condition occurred is documented, so that a chronology can be established regarding the patient’s condition and care. In the event of a future litigation, legal experts will want to know what occurred with precise details.

Use flowsheets to record vital signs…..or not

If your facility uses flowsheets/graphic records (i.e., in the Infirmary), it is certainly acceptable to record vital signs on the flowsheet instead of in the Progress Note. However, it is not acceptable to record them sometimes on the flowsheet and sometimes on the Progress Note. This leads to confusion and the ability to overlook an important measurement. If your facility uses both, a policy decision must be made regarding where to document all vital signs, and it must be followed.

Do not leave blank spaces on chart forms

When a space is left blank, it leaves other caregivers and legal experts wondering whether it was not addressed, the patient did not answer, or the nurse forgot to write the answer/information. If the answer is no, write no or none. If it is not applicable, write N/A or draw a line through the space.

Ensure that only unbiased, objective words are used

Nursing documentation should be based upon fact, not opinions and assumptions. In correctional nursing, we often see the same individuals again and again, and we may form opinions about them based upon our interactions. It is extremely important that we document only our objective observations. In a court of law, if a jury hears that the nurse documented “drunk”, “rude”, “demanding”, “obnoxious”, “malingerer”, “crazy”, “faking” to describe a patient who then ended up with an adverse outcome as the result of lack of medical care, they may believe that the patient received substandard care or attention because the nurse did not like or “approve” of the patient, or he/she/they believed that the patient was faking and did not take his/her/their concerns seriously. Instead, use objective words to describe the patient’s behavior, such as “presented with slurred speech, alcohol smell on breath and staggering gait.”

Next week we will continue our discussion of the Elements of Documentation.

This post is based on The Correctional Nurse Educator class entitled Documentation for the Correctional Nurse. Do you have any elements of good documentation that you would like to share?