ISSUES IN NURSING DOCUMENTATION

Health care requires good teamwork. Nursing care can never occur in isolation. Communication is central. Written documentation and clear presentations of “making a case” for patient intervention are core competencies of nurses. Perhaps nowhere is system design more important than in documentation. A system must be designed with the goals of the practice of all health care team members, the patient’s well-being and safety, and in the context of the actual work environment. A good system of documentation can improve practice, while a poor one may hinder practice.

The purpose of documentation is to clearly communicate the condition of the patient as well as the assessment, planning, implementation, and evaluation work of nursing. It is a continual and ongoing process that reflects the changing needs and conditions of the patient. Documentation is the critical and sometimes only form of communication among all health care providers about the current condition of a patient.

Currently patient care documentation is found in a variety of forms and formats, handwritten and computerized. Written documentation systems have been developed to assist clinicians to produce accurate and comprehensive documentation. Examples include the following: (a) problem-intervention-evaluation charting (PIE); (b) subjective-objective-assessment-plan charting (SOAP); (c) problem-oriented medical record charting (POMR); and (d) charting by exception formats, outcome-based charting; and critical pathways (Meiner, 1999). Checklists for exception charting to address the time restraints have been implemented as documentation requirements for regulatory compliance increase. At times, nurses shortcut documentation because of time constraints or limitations of these forms at the expense of complete charting.

As patient care becomes increasingly complex, the importance of timely and accurate documentation becomes increasingly important. Delays, omissions, and errors in documentation may result in delays or errors in assessments, interventions, treatments, procedures, and medication administration. These errors often create a cascade of events that may negatively impact patient care or patient outcome.

DOCUMENTATION OF THE FUTURE

The written documentation record will increasingly appear in the form of an electronic record. The structure, organization, and retrieval of patient data must be user friendly and secure, and should be designed with the workflow of those documenting their patient care in mind. Computerized documentation systems are more than automation of existing paper forms. State-of-the-art documentation systems are designed to more closely reflect the flow of patient care processes in an orderly way and to increase patient safety within the available features and design. Computerized clinical documentation systems that support functional requirements contribute significantly to patient safety and caregiver effectiveness.

Significant advantages for safe patient care can be realized as electronic systems are implemented across the country. Safe nursing practice is supported in the following ways with an electronic record that includes:

Specific outcomes from computerized documentation that have an impact on patient safety and decrease the potential for practice breakdown include:

Users often develop “shortcuts” and “work-arounds” for a poorly designed system of documentation that does not take into account the workflow processes or the time required for documenting. For example, if there are rigid rules for documenting the administration of medications within one-half hour of administration, and the patient-to-nurse ratio is too high, the nurse may be tempted to document before actually administering the medication. This sets the patient up for undetected “missed doses” of medication. Also, if the workflow and patient care record are poorly designed, requiring excessive amounts of time for access, then nurses may not have a chance to document their assessments and treatments in a timely manner. Nondocumented therapies place patients at great risk for second doses of narcotics, sedatives, or other medications.

The importance of documentation becomes apparent following reviews of incidents in which a patient has been affected negatively. Not surprisingly, documentation is rarely the primary error. The down side of the extensive requirements for documentation in today’s complex hospitals is that the nurse can spend from 13% to 28% of his or her time in patient care documentation, and this reduction in the nurses’ availability to provide direct patient care has been shown to diminish patient safety (Korst et al., 2003; Pabst et al., 1996; Page, 2004).

KEY PRINCIPLES

Key principles regarding documentation indicate that documentation of the current status of the patient is needed and includes assessment, care plan updates, implementation, and evaluation of care provided, and that documentation is a critical task that nurses perform to protect the patient.

The following is a case study in which documentation played a role in the practice breakdown of nursing care. The story is encapsulated for the reader with a sample of the actual documentation provided by the nurses involved. The reader is encouraged to question whether the documentation truly reflects the story presented.

HISTORICAL CASE STUDY #1: Late and Later Documentation

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