Nursing Documentation: Your greatest defense

 Nursing documentation is the record of nursing care that is planned and delivered to individual patients by qualified nurses or other caregivers under the direction of a qualified nurse [1]. Nursing documentation is the principal clinical information source to meet legal and professional requirements [2]. It is a vital component of safe, ethical and effective nursing practice whether done manually or electronically [3]. Nursing documentation should fulfill the legal requirements of nursing care documentation [4].

Documentation is a vital aspect of the healthcare system in rendering quality care to patients. It is a skill that requires accessible, adequate, accurate and timely information to serve its purpose for the patient and also the health care team. Though this is essential, it can be an advantage or fatal disadvantage if not done well.

Principles for Documentation

The aim of documentation is not just to keep record. Even though keeping record is important, it is equally important to keep quality records, this is because standard documentation is needed to promote effective, accurate and individualized patient care.

Therefore, your documentation must align with these principles; 

  1. Factual: a well-documented procedure or event should be descriptive and contain objective data. Example, use descriptive terms such as restless, diaphoretic, tachycardia etc. (do not make statements such as “I think patient is in shock”). and include values recorded and their respective units, example, BP = 70/50mmHg.
  2. Accurate: state exact measurements or state specific results (Example, when documenting 3 milliliters (3mls), be careful not to document 3mg which means 3 milligrams.) and use abbreviations that are institutionally accepted. Example, use RBS (Random Blood Sugar) instead of RBG (Random Blood Glucose) if that’s your institution’s protocol.
  3.  Complete: a complete documentation can be concise but not scanty. Try to write everything significant detail (holistic documentation). This could include what you were told, what you saw and what you did.
  4.  Current: strive to make documentation as soon as you complete the procedure, when it is still fresh in memory. This increases accuracy and prevents delay of appropriate action.
  5.  Organized: reporting in a logical manner chronological order makes it easy to read and interpret the process. Document using the nursing process.
  6.  Eligible: documentation must be neat and eligible to avoid misinterpretation that could lead to clinical errors or inability to carry out medical orders or nursing interventions.

Purpose of Documentation

  1. Nursing Research and educational purposes.
  2. Enhances service delivery or provide quality of care.
  3.  Prevents errors and repetition of procedures.
  4.  Planning of care.
  5.  Nursing audit and financial billing.
  6.  Communication: quality documentation can ensure safe and effective communication. With a good communication, patient care can be enhanced and clinical errors prevented. The healthcare team is made up of varied specialties, responsibilities, expertise and roles who must all come together to work toward serving patients with quality care. Documentation stands as a major tool of communication among the present and future teams therefore break in documentation can determine a break in communication which can alter the entire treatment outcome of a patient.
  7. Medico-Legal Issues

Good documentation is the best defense a nurse can have in the event of a lawsuit (italic ours). Although the principles of nursing documentation are not new, legal cases continue to be lost as a direct result of poor documentation. Nurses must have renewed commitment and vigilance to creating record that will not only ensure patient safety but also provide a defense against allegations of negligence or malpractice.” – Joann Wortham (MSN, JD, CPHQ, CPPS, CPHRM).

 In short, let your pen save you money or keep you out of prison. 

The next few points (by Joann Wortham) can serve as a guide writing a holistic documentation.

  • Describe the event objectively.
  •  Document your assessment.
  •  Chart the care provided, who was notified, and what their response was.
  •  Use a patient’s own words to describe what happened, if appropriate.
  •  Document any change to the plan of care.
  •  Document your reassessments.

Sometimes, the nurse may exhaust everything they can do to sustain a patient in their care and then will notify the appropriate person for assessment (or reassessment) and continued care but the receiving end might just not show up or even refuse to report to the ‘on-call’. In instances similar to this, make it a point to add it to your notes, including the name of the person who was notified, the time, and their response. This might seem like a chore but in case of a law suit, this could save you from trouble since it would be evident that you exhausted the options within your limits.

Nurses and midwives are humans so we do forget certain detail of some procedures we conduct. In that case, what do you do? Let’s find out.

Late Entry

A late entry occurs when a documentation is made after the due, usual or proper time within which the event occurred. It supplies information that was omitted from the original chronologically written entries. So simply put, late entries are made when a procedure carried out or an event that occurred wasn’t documented in the immediate. In such instances, you may forget some details so a late entry should only be written if a nurse has total recall of the omitted information. Always endeavor to make an entry even if it’s late because Late Entry is always sager and better to do than No Entry.

The following points can be used as a guide to write a late entry;

  • Identify the new entry as a “LATE ENTRY”. So do not try to squeeze it into some free space between other entries, create a new one.
  •  Enter the current date and time – do not attempt to give the appearance that the entry was made on a previous date or earlier time. Instead, …
  •  Include the right date and time for which the event occurred in the notes.
  •  The entry must be signed.
  •  When making a late entry, document as soon as possible. There is no time limit for writing a late entry; however, the longer the time lapse, the less reliable the entry becomes.

Addendum/Addenda

An addendum or addenda (plural) in documentation is an addition of text as an appendix or supplement to a document by its author after the document has been printed (written, completed) or published.

An addendum is another type of late entry that is used to provide additional information in conjunction with a previous entry. So the difference between an addendum and typical late entry is that, an addendum is an addition to an entry that has been made already while a late entry is the complete omission of the documentation of an event. Remember too that, an addendum captures information that was not available at the time of entry, so do not make it a habit of using addenda to document information you forgot when making a documentation.

To write an addendum;

  • Document the time and date on which the addendum was made.
  • Write the words “Addendum” and then, state the reason for creating the addendum, referring back to the original entry.
  •  Complete the addendum as soon as possible after the original note. This make it more reliable and comprehendible.

Try to answer these questions.

  1. In course of your busy shift, you recall Mr. Frederick (diabetic patient on insulin therapy) was fed with 1500mls of porridge and served 500mls of water via Nasogastric tube – Addendum or late entry?
  2.  15 minutes after feeding, you observe your patient has a bloated abdomen and is vomiting. – Addendum or late entry?
  3.  4 hours after the incident, patient is observed gasping for breath, SPO2 (on room air) drops to 87% and later patient declared clinically dead and to be prepared for morgue. Immediately after the incident, you sit to document the event. – Addendum or late entry?
  4. 3 days after patients demise, you are awoken at midnight with tachycardia, recalling that you checked Mr. Frederick’s RBS (6mmol/L) but did not capture it in the death notes. – Addendum or Late entry?

Conclusion

Before beginning to write down an entry, create a mental version first to make sure you have adequate information. ASK YOURSELF THESE THREE QUESTIONS;

  • WHAT WAS SAID? – The problem according to the patient (subjective data), history/complains.
  • WHAT DID YOU SEE? – Your assessment, findings, observations (objective data).
  • WHAT DID YOU DO? – Your interventions, orders, effects, efforts etc.

It can be difficult to write enough if you don’t know enough because if you know what to expect, you’ll know what to write. So build your capacity improving your speaking and writing skills. Be familiar with;

  • Medications – adverse effects, side effects, drug mechanism, onset etc.
  • Procedures – catheterization, N-G tube feeding, vital signs parameters etc.
  • Medical conditions – complications, signs and symptoms etc. 
  • Patient condition status – fair, poor, stable, unstable/deteriorating, recovering. Using these wrongly could cause issues. E.g. stating “recovering” for a client who is unstable.

As you carry out your activity on the ward with diligence, please remember without documentation, you have done nothing. But your greatest defense in the profession is not your friend or In-charge but your documentation!

References

[1]. Urquhart C, Currell R, Grant MJ, Hardiker NR. Nursing record systems: effects on nursing practice and healthcare outcomes. Cochrane Data Base Syst Rev. 2009;1:1–66.

[2]. Daskein R, Moyle W, Creedy D. Aged-care nurses’ knowledge of nursing documentation: an Australian perspective. J Clin Nurs. 2009;18:2087–95.

[3]. College of Registered Nurses of Nova Scotia. Documentation guidelines for registered nurses. 2012; http://www.crnns.ca.

[4]. The Federal Democratic Republic of Ethiopia. The criminal code of FDRE: proclamation No. 414/2004. 9 May 2005: Addis Ababa, Ethiopia.

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