ELEMENTS OF GOOD DOCUMENTATION

In our last post, we discussed nine Elements of Good Documentation. This week, we continue our discussion.

Document what the patient tells you with exact quotes

Using exactly what the patient tells you in quotation marks provides an indication of the patient’s mental status and their ability to comprehend what is going on, and it is the information that the patient provided from which you completed your assessment, nursing diagnosis and plan.

Document all allergies to medications, foods, etc.

The documentation of allergies is vitally important, and should be noted on each Progress Note in the health record, the Physician Order Sheet, and all Medication Administration Records for the patient. In addition, the nurse should review all old records available to ensure that all allergies are included on the new record.

Transcribe orders carefully

When transcribing orders, if it is illegible, or there is some question what the order is, contact the Provider for verification. Document in the health record the date and time that you verified the order with the Provider. It is acceptable (and necessary) to question orders by a Provider if they do not seem consistent with the patient’s condition. As nurses, we are first and foremost patient advocates, and we have the education and experience to question appropriateness and discover errors. Be extremely careful using verbal and telephone orders. Ensure that you write the order, then verify it with the Provider prior to implementation. If possible, have another nurse listen to the order and cosign it on the order sheet.

Document care withheld

Just as it is important to document the care given, is the important to document the omission of any care or medication, the reason why and your follow-up.

Document changes in the patient’s condition

Document all changes in the patient’s condition, improvement and deterioration, and what your nursing intervention was to address the change.

Document all information reported to the Physician/Provider

Documentation of attempts at reporting information should be documented in the patient’s chart objectively, for example, “23:20 Paged Dr. Smith to report temperature of 102.5 °F”; “23:40 Paged Dr. Smith to report temperature of 102.5 °F”; “0010 Spoke with Dr. Smith and reported temperature of 102.5 °F; orders for Tylenol received”; “0015 Medicated with 650 mg Tylenol po per MD order.” In addition, complete and precise documentation of the information provided is extremely important, as it will demonstrate that the professional obligation of the nurse was fulfilled with regard to their caring for the patient and communicating with the members of the healthcare team regarding the patient’s status. The time of the contact and the name of the provider should be documented, as should their response. If the response is not expected, i.e., “watch the patient and call back in 2 hours,” document the order and “watch the patient”. However, if the patient’s condition worsens prior to the two hour callback timeframe, prudent nursing care dictates that the provider is recontacted immediately.

Document only care that you personally gave, or supervised

Signing a health record entry means that you have reviewed it and are ultimately liable for those actions. Documenting the actions of unlicensed personnel and their observations may be part of your job description, but remember to evaluate the information presented, and, if there is a question regarding a patient’s status, reassess the patient. Cosigning a student nurse’s note also indicates that you have read the note and agree that the care provided by the student nurse was appropriate.

NEVER alter a Health Record

Altering a health record includes the following activities:
• Adding to an entry at a later date without documenting that it is a “Late Entry”
• Including inaccurate information in the health record
• Omission of pertinent facts
• Altering the dates so that it appears as though the entry was written earlier than it was • Rewriting the health record
• Destroying pieces of, or a complete, health record
• Adding information to another healthcare team member’s entry

COMMON DOCUMENTATION ERRORS

Finally, research by nursing organizations and risk liability companies has identified common documentation mistakes made by nurses in all fields. They include the following:

• Failure to record pertinent health or drug information
• Failure to record nursing actions
• Failure to record administered medications
• Documentation in the wrong patient’s medical record
• Failure to record discontinued medications
• Failure to record drug reactions
• Failure to record changes in the patient’s condition
• Transcription errors
• Illegible or incomplete Records

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?