Nursing On Point

Snapshot: This article provides an overview of nursing documentation, including a discussion of its importance, documentation guidelines, and how documentation fits into nursing practice as a whole.

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What is Documentation, and Why Is It Important?

• Documentation is the record of your nursing care. Documentation is the primary way that we, as RN’s, demonstrate what we did, for whom, when, and with what effects. Documentation encompasses every conceivable form of recordable patient data and information, from vital signs to medication administration records to narrative nursing notes.
• Documentation is a legal record. Documentation is not merely “record keeping”; the documentation that comprises a patent’s medical record is also a legal document. Documentation is therefore a means for others to assess whether the care that a patient received met professional standards for safe and effective nursing care, or not.
• “If it wasn’t documented, it wasn’t done.” From a professional (and legal) standpoint, this is entirely true. In this sense, documentation is how we “prove” what we did (or didn’t) do in the course of caring for our patients. For this reason, documentation isn’t peripheral to your job as an RN, it’s central to it.

Documentation Guidelines and Tips

• Document clearly and accurately. Avoid abbreviations, acronyms, and medical jargon. Keep in mind that documentation may be read by patients and other individuals without clinical training. Not everyone may know that “HTN” means “hypertension,” that “WNL” means “within normal limits,” and that VSS means “vital signs stable.” Even some RN’s and other clinicians may disagree about the meaning of various terms and acronyms. Avoid confusion by spelling things out.
• Avoid vague terms and generalizations. When you document, be as clear and specific as possible. For example, don’t use vague terms like “small” to describe a pressure ulcer (decubitous ulcer); instead, write something like, “stage II decubitous ulcer in sacral area, 1.5 cm width x 1 cm breadth x 0.5 cm deep; no drainage or tunneling present.” If you’re noting how much a patient ate, don’t write, “patient ate some of her meal.” Instead, write something like, “patient ate approximately 50% of food on lunch tray.” If you’re unclear, others either won’t understand what you meant, or worse, may assume that for some reason you’ve deliberately omitted clinical information.
• Document what you did or observed, not your opinion. One of the big no-no’s in medical documentation is to shade your charting with opinion, rather than stick to the facts. For instance, you should never chart something like, “Patient uncooperative, will not take medications.” Instead, simply write, “Patient refuses medications.” If a patient is rude, inappropriate or even hostile, don’t record those subjective judgments in your notes; instead write, “Patient made verbal threats toward myself and other staff members; per hospital’s safety protocol, security personnel called to patient’s room.” Whatever the circumstances, you should record observations, actions and events, not judge them.

Documentation: The Big Picture

• Documentation is the most important at the most challenging times. When things are going smoothly, there’s usually plenty of time to document in an accurate, detailed, and timely manner; when things aren’t going smoothly, there can hardly be enough time to document at all. But it’s precisely when things aren’t going well – for instance, after a code, or after a complex patient admission, discharge or transfer – that it is most important to document well. After all, what are the chances that someone will examine your charting if your patient faces no complications? Probably low. This predicament isn’t necessarily problem, but it is worth bearing in mind. Even if you’re exhausted or have to stay late to document after a challenging clinical encounter, it’s worth it because during these times clear, accurate and timely documentation is especially important. Even if things don’t go well for your patient, if you’ve documented well you can protect yourself and the nursing license you worked so hard to obtain.
• Develop good habits. Documenting well is sort of like brushing your teeth; it can be time-consuming (and sometimes annoying), but if you’ve gotten into the habit of doing it – if it’s an almost automatic part of your day – then it’s much more likely you’ll do it consistently and well. As you gain experience and confidence, it can be tempting to let the quality of your documentation slip. If no one’s ever questioned or audited your charting (at least to your knowledge), you may even mistakenly convince yourself that documentation isn’t important after all. Don’t fall into that trap. When you let your documentation slip, you jeopardize yourself and your license, and beyond this, you make it much more likely that you’ll forget to document (or fail to document well) after a challenging clinical encounter when it is vital to prove that the care you provided was professional and safe.
• Documentation lasts forever; liability doesn’t. Here’s a piece of good news: even though your nursing documentation will become a part of your patients’ permanent medical records, you don’t have to worry about if or how that documentation could come back to haunt you forever, at least from a legal point of view. The statute of limitations for most medical malpractice cases is two years. This means that, no matter what happened to a patient you cared for (or how shoddy your documentation of those events may be), a patient and his or her lawyer would have a very difficult time holding you or other healthcare professionals liable for any oversights or wrongdoing after that time. While RN’s are only infrequently named in malpractice suits, and while unsafe nursing (demonstrated via documentation) could still jeopardize your license after this period, it is helpful to know that patients must act within this window of time if they wish to take action against you. Hopefully you’ll never face a lawsuit or sanction on your license, but this is important information to possess nonetheless.

Related Pages

• Documentation, Laws & Regulations
• Core Measures
• HIPAA for Nurses
• National Patient Safety Goals
• Nursing Documentation