Documentation is considered as a vital communication tool among healthcare professionals.
Bad documentation can make a good nursing look bad and can make a bad nursing look even worse.
We all appreciate the fact that proper documentation is not just an
indispensable tool for effective and efficient nursing care, but also a
safeguard against ethicolegal infringements that the nurse may face in
the course of discharging his/her nursing duties.
But due to alot of factors especially in Nigeria today, nurses tend to only pay attention on the cumbersome job at hand, giving their all to ensure that the task is accomplished and barely paying the needed attention to their documentation, despite actually performing their work judiciously, not acknowledging the basic fact that not documenting your work is as bad as not doing the work.
Among such factors leading to the failure of documentation among nurses include:
1. Poor staffing
2. Work overload
3. Ambiguous working environment
4. Lack of adequate equipment
5. Lack of proper orientation
6. Lack of existing institutional policies and guidelines on documentation
Nursing documentation is an integral part of clinical documentation and is a fundamental
nursing responsibility, with professional, legal and financial ramifications to both the nurse as well as the hospital.
Good documentation ensures continuity of care, furnishes legal evidence of the process of care and supports evaluation of patient care.
Nurses must balance clinical documentation with respect to legal imperatives. Accurate and complete documentation of client’s symptoms and observations is critical to proper treatment and management. Entries documented on a client’s clinical record are a legal and permanent document.
Nursing documentation is any written or electronically generated information that
describes the care or service provided to a particular client or group of clients. Through
documentation, nurses communicate to other healthcare professionals their observations,
decisions, actions and outcomes of care.
Documentation is an accurate account of what occurred and when it occurred.
In the process of documentation, the nurse needs to consider the following:
1. Enforce local policies and procedures or protocols of documentation at practice setting and that nurse follows these at all times.
2. Ensure clear, concise, accurate, complete, objective, legible and timely documentation to fulfil both clinical and legal imperatives.
3. Exercise professional judgment and apply knowledge and skills in the given situation.
Objectives of Nursing documentation
1. To show evidence of the provision of quality nursing care
2. Facilitates the advancement of efficient and effective health service programmes
3. To create a legal record of nursing services, treatments and communication provided to patients
Responsibilities of the nurse
1. The nurse understands his/her accountability for documenting on the clinical record the
care he/she personally provides to the clients.
2. The nurse documents the care process including information or concerns communicated to
another health care provider.
3. The nurse documents all relevant information about clients in chronological order with date
4. The nurse carries out comprehensive, in-depth and frequent documentation when clients
are acutely ill, high risk or have complex health problems.
5. The nurse documents timely the care he/she provides.
6. The nurse corrects any documentation error in a timely and forthright manner.
7. The nurse remarks any late entry, if indicated, with both date and time of the late entry and
of the actual event.
8. The nurse indicates his/her accountability by adding his/her signature and title as approved
by his/her organization to each entry and correction he/she makes on the clinical record.
9. The nurse safeguards the privacy, security and confidentiality of clinical record by
appropriate storage and custody.
10. The nurse updates himself/herself with contemporary documentation knowledge.
Legal pitfalls of improper documentation
1. Faulty record keeping practices
2. Absence of information
3. Charting after the fact
4. Missing records and time gaps
5. Vague entries
6. Late entries
7. Improper corrections
8. Unauthorised entries
9. Use of unauthorised abbreviations
10. Illegible handwriting
11. Documenting personal opinion
How to avoid the legal pitfalls of Nursing documentation
1. Number, date and sign all entries
2. Use generally accepted medical abbreviations
3. Document immediately or soon thereafter when caring for your patient
4. Document exactly what you see, hear or smell
5. Avoid innuendos
6. Avoid use of correction fluid
7. Avoid writing with pencil
8. Do not chart for others
9. Avoid record tempering
10. Do not leave blank spaces for others to chart later
11. Maintain privacy
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2.Journal of Clinical Nursing. 12, 206-214.
Brooks, J. T. (1998). An Analysis of Nursing Documentation as a Reflection of Actual Nurse Work. Medsurg Nursing. 7(4), 189-198.
3.Cheevakaesmsook, A., Chapman, Y, Francis, K. and Davies, C. (2006). The Study of
Nursing Documentation Complexities. International Journal of Nursing Practice. 12, 366-374.
4.College of Registered Nurses of British Columbia. (2008). Nursing Documentation (Practice
Support – pub. 151). Online Retrieved Jul 10, 2008 from http://www.crnbc.ca
5.College of Registered Nurses of British Columbia. (2008). Documentation (Practice
Standard – pub. 334). Online Retrieved Jul 10, 2008 from http://www.crnbc.ca/Nursing
Ioanna, P., Stiliani, K. and Vasiliki, B. (2008).
6.Nursing Documentation and Recording
Systems of Nursing Care. ICUS Nurs WEB Journal, Issue 30-31. Online. Retrieved Jul 10,
2008 from http://www.nursing.gr
7.Mahler, C., Ammenwerth, E., Wagner, A., Tautz, A., Happek, T., Hoppe, B. And Eichstadte, R. (2007). Effects of a Computer-based Nursing Documentation System on the Quality of Nursing Documentation. J Med Sys. 31, 274-282.
8.Pyrek., K. M. (2008). Documentation is Crucial to the Medico-Legal Process. Online.
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