Documentation allows for clear communication between healthcare team members; provides a full accounting of patient care to support reimbursement, ensure quality care, and reduce errors; can be used as evidence in legal matters; and generates data for research and quality improvement initiatives. The challenge for nurse educators is ensuring that graduate nurses not only have the necessary skills for effective documentation, but also understand the risks of poor documentation to their patients and themselves. This challenge is compounded by a lack of recent literature on generating effective documentation.
This article reviews the rationale for documentation and its essential components, and offers a memory aid to assist students in developing effective documentation skills.
The expectation is that all documentation should be clear, concise, comprehensive, accurate, objective, and timely. Nursing organizations have developed position statements and guidelines that give a broad overview of what information to include, how often documentation should be completed, and how to format entries and errors. Facilities supplement these guidelines with policies delineating specific documentation requirements, standard definitions of assessment findings considered within normal or expected limits, expected intervals for assessments, and time frames for completing documentation. Position statements and documentation guidelines include:
For example, the ANA provides guidance and recommendations not only for nurses, but also facilities, patients, healthcare systems, and educators. The ANA outlines the components of proper documentation and addresses institutional responsibilities. Nurse input into the design of EHRs and participation in trials of new systems is encouraged.
The ANA also recommends that facilities ensure staff members have adequate training to become proficient in using documentation systems. Additionally, facilities are urged to provide staff with adequate time to complete effective documentation. Including nurses in decision-making related to EHRs, providing necessary training, and factoring the time needed for documentation into staffing decisions ideally reduces the risk for poor documentation practices while increasing the quality of patient care and communication between healthcare team members.
As stated previously, documentation serves many purposes, but the two uses that garner the most attention are the legal and patient safety aspects. The patient's EHR is considered a legal document and can be used in a court of law to exemplify the quality of patient care, or its lack. The EHR, in effect, becomes an impartial witness to the care delivered to each patient by the healthcare team. For this reason, documentation must be exacting in its accuracy. Only actions completed or witnessed by the person documenting should be included. Subjective statements and opinions shouldn't be included in the EHR because they aren't quantifiable. Accurate, complete, objective documentation protects not only the patient, but also the healthcare professional.
Correct documentation also ensures patient safety. The EHR serves as a means of communication between healthcare team members from different shifts and disciplines. It's difficult to include every event occurring during a 12-hour shift at the patient handoff report. As a result, it isn't unusual to see nurses review the documentation from previous shifts to compare their findings with earlier assessments, confirm a suspected trend in vital signs or lab values, or verify that recent orders and appropriate notifications have been completed. Complete, concise, and accurate documentation allows needed information to be located quickly, decreasing the likelihood that complications will occur.
Documentation should communicate assessment data, changes in patient condition, interventions and treatments provided, response to treatment, all patient transfers to and from different areas of care, and communication with members of the healthcare team and family. Assessment data should include not only the results of the physical exam, but also vital signs, lab values, and results of diagnostic procedures. Facilities dictate the minimum frequency of this type of documentation. When a change in patient condition is noted or suspected, additional assessment and documentation are warranted.
Interventions and treatments provided during patient care by all healthcare team members should be included, as well as the patient's response to these activities. All actions performed by the nurse should be documented in detail. Additionally, nurses should document the occurrence of actions performed by other healthcare team members. The individual performing these activities will complete detailed documentation of the intervention, whereas nurses will document when they occurred, who completed them, and the patient's response. For example, a dietitian or wound care nurse will detail his or her visit in the progress notes; the nurse will note the time of the visit and any orders received so nurses during subsequent shifts will be aware of additional orders and who to contact for questions or changes in patient condition.
A timesaving feature of the EHR is the ability to document by exception. Before the implementation of EHRs, documentation included all findings, normal and abnormal. Documenting by exception is designed to save time by allowing members of the healthcare team to note only findings that differ from the expected during an exam or procedure. If the assessment findings match the facility's predefined designation of normal or expected, within normal limits (WNL) may be selected and no further information for that section is required.
It's vital to be familiar with the facility's definitions for each area of the EHR to ensure accuracy in documentation. As helpful as the WNL feature can be, it presents a problem for educators when instructing students about documentation. Just as the normal range of lab values can differ slightly between facilities, the definition of WNL will mirror these slight variations. Educators test lab values in accordance with the school's chosen text while cautioning students to expect variation in their clinical setting and emphasizing the need for situational awareness. Instructing students in the appropriate use of WNL should be addressed similarly.
Without an EHR
The 2009 American Recovery and Reinvestment Act required all healthcare facilities and providers to incorporate EHRs into patient care by January 1, 2014, to continue receiving their existing level of reimbursement for provided Medicare and Medicaid services. As a result, traditional paper documentation is virtually unknown to many nursing students and new nurses. Without the EHR to prompt what information to include, students often include either too much or too little information. Students can undervalue the need to practice documentation skills in their reliance on available technology. When working with students, it's important to emphasize that EHRs won't always be available.
In a study of downtime errors, it was found that when an EHR is functional 99% of the year, facilities are still without EHR capabilities for 3 days and 15 minutes annually. In the case of natural disasters or fires, healthcare facilities can be without EHR access for days or weeks and documenting must be done on paper. And it isn't only natural disasters and environmental hazards that pose a threat to EHRs. Recently, cyber-attacks have become more commonplace. During this type of attack, a ransomware virus encrypts all hospital data until a ransom is paid. Hospitals may need to stop using the EHR for days while protective systems are put into place.
Many hospitals have physician portals in place so providers can access patient information from their homes and mobile devices. When systems are down for any reason, providers must rely on other healthcare team members to keep them informed in a timely manner and increase the number of rounds or time spent rounding. Communication between units, the lab, pharmacy, and other departments can also be delayed. Orders and results must be faxed between locations, increasing the risk of errors in both ordering and reporting.
Facilities will likely have downtime flowsheets to record vital signs, medication administration, and physical assessments; however, documentation of events and treatments must be made individually by hand. For these reasons, it's imperative that students understand the components of effective documentation, regardless of the method.
Documenting with students
Written errors, signatures, and forgotten information are the simplest aspects of documentation to address with students. Miswritten information should have a single line drawn through, followed by the initials of the documenting nurse. Erasable pens and correction fluid or tape should never be used in patient records. When signing a written order, a single line should be drawn through the remainder of the row before the signature to prevent unauthorized addition of information. Facilities will have clear expectations regarding late entries; nevertheless, each delayed entry should be given the current date and time, identified as a late entry, and followed by the information that would've been provided had the entry been timely (see Documentation quick guide).
Providing instruction regarding what information to include when documenting an event or intervention is more challenging. Making decisions regarding what and how much information to include can be a source of frustration for students when practicing documentation during various activities. Memory aids can be effective tools to assist students in the decision-making process. For example, use of a color-coded keyword technique in which each piece of needed information is assigned to the fingers and palm of the hand provides a checklist to ensure the inclusion of all necessary data (see Documentation memory aid).
Assigned categories of information include:
- when (pinky finger)
- materials (ring finger)
- what (middle finger)
- how/why (pointer finger)
- measure/assess (thumb)
- patient response (palm).
Each entry begins with the time and date (when) to establish the timeline of care. Next, document the materials used for the intervention (materials). This includes information such as I.V. catheter size, materials used for a dressing change, or the dose of an as-needed medication given, to name a few. Third, describe or name the intervention (what). Fourth, include the rationale for the intervention and any special positioning or method used, such as high Fowler position or sterile technique (how/why). Next, provide appropriate postintervention assessments or measurements (measure/assess). Finally, note the patient's response to the intervention (patient response). Color-coding allows students to visualize how each portion works together to create a complete, concise entry.
Do's and don'ts
As stated previously, correct documentation is accurate, concise, timely, legible, and provides precise information such as “50 mL of serous drainage” versus “a small amount of drainage.” However, there are a number of ill-advised practices that students are likely to encounter at some point during clinical experiences (see Documentation do's and don'ts). One of the most common habits to avoid is the use of copy/paste. It isn't uncommon for nurses to enter their initial assessment information and copy/paste all remaining assessments for the day, scrolling through quickly for updates or changes. Often, this copy/paste function can be used when caring for the same patient on consecutive days by copying the last assessment of the previous day. Although the intention is to save time, it's easy to miss changes in patient condition or include care provided at a previous time.
Other practices relating to timeliness are “pre-documenting” and delaying documentation until the end of the day. Pre-documenting is documenting care before it occurs; in essence, documenting something about to be done. Unexpected findings that aren't added to the pre-documentation can result in inaccuracies. Unplanned events can prevent the care from taking place, leading to falsified care. Conversely, delaying documentation until the end of the day often results in the omission of details relating to care and patient condition, and may delay recognition of a negative trend in condition.
One last caution for students is to avoid “autopilot” documentation. In their desire to document quickly for all assigned patients, nurses can hastily document assessment information from habit rather than observation. We've all heard about, or seen, the medical record indicating pedal pulses are present on a leg with a below-the-knee amputation. This contradictory documentation leaves the healthcare provider and the facility legally at risk in the event of a negative outcome.
Students often have challenges with learning how to effectively document. As educators, we need to develop methods to ensure that students not only understand the larger issues of accountability related to documentation, but also the basics of how to notate errors and what to include in an entry. Dismissing documentation as a nuisance that can be abbreviated when demands on time become overwhelming increases the risk to patient safety. Accurate documenting is quality patient care.
Documentation memory aid
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