Understanding the Importance of Documentation

Documentation and verbal communication is an essential part of any heath care professional’s daily routine. Any and all discussion and care provided to a patient, caregiver or family member has to be recorded accurately and without prejudice or judgement. Just the facts.

Sounds simple, but it can become very complex and time consuming rapidly. If it’s not done at the time, a lot can be lost or omitted. A recent article about a small study done with paramedics using body cameras to verify and improve their documentation actually did support the use of these cameras. They were expected to document as usual at first and then allowed to view the videos and edit their documentation based on the viewing.

The question that came up about using this process widely is one of privacy. It would have to pass the HIPAA test before it could be approved, and patients would have to have the right to refuse to have their situation recorded.

Documentation Provides Accuracy of Events

Documenting conversations and events recently came under a lot of scrutiny and question when it was noted that the former FBI director, James Comey, has “memos” of his meetings with President Trump and other members of the administration. They are reported to be very detailed as is his nature. Many people were shocked he would have documented his meetings and felt this to be out of line. But Comey was the “top cop” and what do police, FBI and other investigators do? They take copious notes from which they build their investigation. Even in situations which may not be under investigation, they will make copious notes in case it does come up later, when they may have no recall of the situation. To health care professionals, documentation is second nature.

nurse documenting

Nurse documenting

This situation (regardless of any political implications) serves as a reminder to all health care professionals that documentation is essential and expected to be complete and detailed for the best outcomes. Paramedics may have very short contact with a patient, but the documentation is perhaps even more important to detail it as opposed to the longer events. Detailing important information as the situation plays out helps to ensure the event is accurately documented. It’s not always possible, and the event gets recorded after it has transpired based on the recall of the documenter.

Documentation Evidences Effectiveness and Outcomes

In a hospital setting, nurses will spend their shift (4, 8, or 12 hours) with several patients, and they need to document on each of these patients minimally every 2 hours. To say everything is within normal limits, or unchanged, is not acceptable. There are NO shortcuts to good documentation. The patient is in an acute care setting for a reason, and measurable gains or declines are necessary to support continuation of the care, reimbursement, and to detail the response and outcomes based on care, education and treatments given.

A body camera could be very helpful for busy nurses to recall all the details especially when the unexpected occurs and their day is turned on its head. Until that time, nurses need to document frequently and keep detailed notes as the day progresses to help them recall anything they may have overlooked or forgotten.

The EMTs and paramedics that nurses respect and appreciate the most are those who provide accurate, concise but detailed documentation and communication with handoff to the ER or other units. Those looking to become nurses will make their transition easier and better by honing documentation and communication skills.

Resources:

17 Tips to Improve Your Nursing Documentation

Do’s and Don’t of Documentation – NSO

Charting and Documentation Guide for Nursing Students

 

 

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