If you didn't chart it....did you do it?

This is about nursing documentation.  Information comes from Davis Advantage for Fundamental Nursing Care by Marti Burton and David Smith

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welcome back to Nursing Together, the podcast where we take the information you've learned in nursing school and connect it to what you actually do at the bedside. Today, we are gonna be talking about something that may not feel as exciting as starting an IV, administering medicine, or performing CPR. But what I want you to remember is that documentation is nursing care. In fact, documentation is one of the most important things that you will do every shift. Before nursing school, you may have pictured nursing as a physical thing you do for the patient, like give medicines, take vital signs, dressing wounds, helping someone breathe, or holding a patient's hand during a difficult moment. And yes, all of those things are absolutely true and absolutely nursing. But there is another important part to nursing that happens before, after, and sometimes while you're providing the care, it is documentation. But there's another part of nursing that happens after, or sometimes while you are providing that care. You document it. Documentation is the act of recording pertinent medical information in a patient's medical record. That record may be handwritten on paper or entered electronically into an electronic medical record or an EMR, and that record becomes a permanent medical record or a permanent part of that patient's medical record. So today we are going to ask some important questions including: What should I document? How should I document it? What makes documentation good or dangerous? And perhaps most importantly, does documentation have to do with patient safety and the law? So let's go ahead and get started Let's begin with the big picture. Your patient's medical record has four major purposes. Think of these four reasons why you document. Number one, communication. Documentation communicates pertinent information to everyone involving the patient's care. Remember, nurses dont provide continuous care twenty-four hours a day. Other members of the healthcare team may only see the patient periodically. The physicians may come once or twice. Physical therapy may only see the patient for like an hour and respiratory kinda comes and goes as needed. Dieticians evaluate only the nutritional need. But you on the other hand, as a nurse, need to know all of it. So understanding that medical record is important for your day-to-day activities. Your documentation tells not only the next person who's, caring for the patient, but also the other medical people involved on what happened, what changed, what did you do? How did the patient respond? And what still needs to happen. This is called a continuum of care. Imagine you're caring for a patient with pneumonia. At eight AM, the patient has shortness of breath and his oxygen saturation of eighty-nine percent. You intervene. You apply oxygen according to the order. You reassess the patient. The oxygen saturation improves to a hundred percent, and you document all of this. Now, the nurse who is coming in at nineteen hundred doesn't have to guess what happened during your shift. Your documentation provides the picture of the patient's condition and the response to the treatment number two, documentation provides a permanent record. Your patient's chart is not simply a collection of notes for today's shift. It becomes part of the patient's medical record. Someone may look at records months or even years later. Previous assessment, diagnostic results, treatments, medications, and the patient's response can help a healthcare provider understand what is happening to them today and how it might help them in the future. So when you document, think beyond, "My instructor is going to check my charting." Instead, think, "Someone may need this information in the future to make a decision about patient care." That changes how you approach documentation. Number three, accountability. Documentation allows health care organizations to evaluate the quality of care that is being provided. Records can be reviewed for such things as infections, falls, adverse events, outcomes, and other quality indicators. Accrediting organizations, including The Joint Commission, may review these medical records to determine whether the healthcare organizations are meeting established standards. And documentation can affect reimbursement. Insurance companies and other third-party parties often require specific information to be documented into the medical record. So, documentation isn't just a nursing responsibility. It affects the patient, the nurse, the organization, quality metrics, accreditation, and reimbursement. Number four: Documentation is a legal record. And this one is especially important. Your documentation may be used as evidence in legal proceedings. It may potentially help a patient establish if Neglect or malpractice occurred. But accurate documentation can also help protect the healthcare provider. This brings us to one of the most familiar phrases in nursing. "If it's not charted, it's not done." Now, I want you to understand this phrase correctly. It does not mean that every time you forget to document something, the care magically disappears. But from a legal and professional perspective, missing documentation can make it extremely difficult to demonstrate that care actually occurred. Your memory may not be enough. Imagine being asked several years later, "What time did you assess your patient? What were the patient's vital signs? What did you observe? What interventions did you perform? How did the patient respond?" You probably won't remember, but your documentation can provide the record to help you remember what was going on. That is why documentation is considered written evidence. Now let's talk about one of the most important standards. Your documentation must be accurate. As an LPN, you are legally and professionally responsible for your documentation. You should never document something you did not do, and you should never document that something happened when you don't actually know that it happened That sounds obvious, right? But let's look at how easy it can be to accidentally create a problem. Suppose you walk into a patient's room and find the patient lying on the floor. You didn't see the patient fall, so you document "Patient fell out of bed." Why? Because you didn't actually see what happened. Instead, your documentation should reflect what you actually observed. So for example, "patient found laying face down on the floor at the side of the bed. Patient state I was trying to reach for my telephone." Do you see the difference? The first statement is an assumption. The second documents objective findings and identifies the patient's statement. That is the difference between an interpretation and objective documentation objective versus subjective documentation. This is one of those concepts that you need to become extremely comfortable with. Let's say you are writing, "A patient is acting strange." Is that objective? No. Strange means different things to different people. Instead, describe what you actually observed. Maybe the patient is staring at the wall, responding slowly to a question and repeatedly attempting to get out of bed. Those are observations. Or perhaps write, "Patient tolerated diet well." Well, what does well mean? Did the patient eat a Hundred percent? Did he eat fifty percent? Did he have nausea? Did he vomit? Were you able to see him swallow without difficulty? Instead of saying tolerated well document the actual information that supports your conclusion. For example: Consumed seventy five percent of clear liquid meal; denies nausea; no vomiting observed now another nurse will know exactly what happened. The rule is simple. Don't make the reader interpret your documentation. Give them the facts and the facts only. Your documentation should be accurate, factual specific and objective and free of judgment language. The Five Senses of Documentation Here's a useful way to remember objectivity. Ask yourself, "What did I actually observe?" You can document what you see, hear, smell, feel through touch and what you can assess using appropriate clinical techniques. You can also document what the patient tells you. For example, the patient says, "My pain is eight out of ten." But that is subjective information, but it is still important information, so you document Patient reports pain eight out of ten in the right lower abdomen. Then document your objective findings and your interventions. Maybe you administered the medicine according to the order, then reassessed. Perhaps thirty minutes later, the patient reports pain was four out of ten. That sequence is a powerful documentation: assessment, intervention, response. You are showing what happened, not simply stating your opinion Timing matters. Let's talk about another major documentation standard, and that's timeliness. Ideally, documentation should occur as soon as possible after care was provided. Assessment data are obtained or even as it occurs. Why? Because memory is unreliable, especially when you are caring for multiple patients. Imagine you have taken vital signs on six patients. You've administered medication. You helped one patient to the bathroom. Another patient suddenly becomes short of breath. Someone else needs pain medicine. The physician wants an update. The phone is ringing, and now your instructor is asking you a question. Now try to imagine yourself saying, "I'll chart everything at the end of the shift." That is dangerous. You may remember what happened, but you will not remember exactly when it happened. Will you remember exactly what the vital signs were? Can you tell exactly what happened before and after the intervention happened? Maybe, and maybe not. That is why it is important that documentation happens as soon as possible. You cannot document immediately. Make a quick note of the relevant information and the exact time so that you can enter it into the record as soon as possible. But there's an extremely important rule when it comes to documentation. Never document anything before it happens. Charting care before it actually happens is actually considered fraudulent Let's imagine this scenario. Your documentation says that at nineteen thirty your patient was lying quietly with his eyes closed. Respirations were even and regular. Sounds fine, right? But what if the patient was actually in MRI from nine nineteen until nineteen fifty-five? But what if your patient was actually in MRI from nineteen ten until nineteen fifty-five? Now your documentation creates a problem. Your chart says your patient was in the room. The record states that the patient was somewhere else. That is why accurate timing matters. Unfortunately, that patient might have coded in the MRI, and now you're stating that that patient was lying quietly with respirations even and regular when they were actually having an episode in the MRI. Your documentation should occur in chronic- chronical order with specific time entries. Avoid documenting huge blocks such as eighteen thirty to twelve thirty, patient was stable. That's not very useful. Instead, document significant assessments, interventions, and patient's response at the appropriate time. Remember, time tells a story. Now, there's something else the student sometimes struggles with. Documentation needs to be complete. But that doesn't mean it needs to be a novel. You don't have to write a five-paragraph essay every time you document. Good nursing documentation is brief, concise, specific, relevant. The goal isn't to write more; the goal is to communicate what matters. Think about this: Patient is doing good today. Not useful at all. Compare it to ambulated a hundred feet with a walker and one person assist, denies dizziness or shortness of breath. That is concise but meaningful. Your documentation should allow another nurse to understand the patient's condition without having to decode it on what you meant Remember to only use appropriate abbreviations. This is important because abbreviations can create confusion and medication errors. Your facility will have a list of approved abbreviations and symbols. You are responsible for knowing what those facilities, symbols, abbreviations, and policies are. Don't assume that the abbreviation is acceptable just because you've seen it somewhere else and have used it. And this is especially important; never use an abbreviation that your facility prohibits. When you're a student, get into the habit now. When in doubt, spell it out or check with the policy Most of you will be spending a significant amount of time of your nursing career documenting electronically. An electronic medical record can make documentation easy, but electronic documentation can create its own risk. One of the biggest ones is copy and paste. You may see a previous nurse's documentation and think, "That's exactly what I need. I'll copy it and just make a few changes." Don't. We do not need to start the bad habit of copying and pasting as a shortcut. Why? Because copied documentation may no longer accurately describe the patient's current condition. Your patient can change. Your patient will change. Your assessment needs to reflect on what you found, not what someone else found six hours ago. Never leave documentation blank without understanding your system. Another important concept is avoiding unexplained blank spaces. In electronic documentation your facility may direct you to use such terms as N/A, denies, not observed when appropriate rather than just leaving a field blank. Again, follow your facilities' policies and specific EMR rules. The larger lesson is this. Don't leave medical records ambiguous Remember, another big element is your logon is your signature. So let's talk about electronic security. Your username and password aren't just a way for you to get into a computer; they are tied to your identity and to your documentation. Never allow another person to use your login, never share your password, and when you are finished documenting, log out. Why? Because if you walk away from an open computer, another person could potentially enter or change information underneath your name. That means your name could appear on the document, and you didn't even do it or enter it. Think of your electronic signature the same way you would think about signing a paper chart: protect it. Now let's connect documentation to another critical nursing responsibility, confidentiality. Your patient's health information is private. That means you don't discuss your patient's information in the elevator, in the cafeteria, at the nurse's station where other people can hear, on social media with friends, with family members who aren't authorized to receive information. You should never access the chart of someone simply because you're curious. There are rules that govern this, and your password once again is what allows people to know whether or not you have been into someone else's chart. Remember that HIPAA protects patient health information. Confidentiality is not an option; it is part of being a professional nurse Now let's go ahead and try to talk about something that students frequently misunderstand, and that's incident reports. An incident report is called a variance report or used when something unusual un-- or unexpected happens. Examples may include a medication error, a patient getting injured, a visitor injury, an employee injury, a safety hazard, fail to perform an order of care, losing patients' belongings, or a lack of necessary equipment or supplies. But here's the important part. The incident report is not a part of the patient's medical record. It is maintained separately according to the facility policies. So if your patients fall, what do you do? First, and of course, foremost, take care of that patient. Assess the patient, provide appropriate care, notify appropriate people according to the policy, then complete your documentation based on the interventions that you did on that fall, and then complete the required incident or variance report. Make sure that they know what has happened, what, what you documented, what happened with that patient, the assessment, the care, the interventions, the notifications, and the response. Don't just write "Incident report completed." Make sure you have all of the information and make sure that the chart can tell the story of the patient's condition and the care that was provided Documentation errors that can seriously hurt a patient. Let's finish with five documentation mistakes that carry an increased risk of malpractice or negligence. These are worth remembering. One, failure to document assessment findings. If you discover an abnormal finding, document it. Don't assume everyone else has documented it for you. Even if you reported it to your supervisor, you are still responsible for documenting your own assessments and your own findings, and the actions that you took. Two, failure to document medication administration. When you administer a medicine, the record needs to accurately reflect the medicine dosage route, and time according to the facility policies. So why is that important? Imagine you give medicine, but you forgot to document it. Another nurse sees no documentation and assumes that the medicine wasn't given and then gives it again. Now your patient may receive an unintended extra dose. So medication documentation isn't paperwork, it is part of patient safety. Number three, failure to document Pertaining to health history. Think about allergies. A patient's allergies that isn't documented could result in a patient receiving something potentially dangerous. Other important information may include significant diagnosis, previous infections, or other healthcare histories that affect care. If it's clinically important, make sure you communicate it and document it appropriately. Number four, documenting on the wrong chart or medical health record. This can happen more easily than you think, especially with EMRs and patients with a similar name. Before documenting or administering medicines, verify the patient's identification using the required identifiers. Don't rely on room numbers alone. Don't rely on familiar faces; verify. Number five, failure to accurately document physician's orders. Orders are the foundation for many aspects of patient care if an order isn't accurately transcribed, communicated, or entered according to the facility's procedures, the treatment may not happen. So documenting errors can become an error, and care errors can become patient harm. So as you move into th- your clinical practice, I want you to develop a particular mindset. Before you put anything into the medical record, ask yourself five questions: Is it accurate? Is it objective? Is it timely? Is it complete? Is it confidential? As we wrap up today's episode, I want you to think about something. Imagine that another nurse has never met your patient. They don't know the patient. They weren't there when you performed your assessment. They didn't see what happened during your shift. They weren't there when the patient's condition changed. They don't know whether the patient improved. The only thing they have is a record. So remember, your documentation tells a story, and that story needs to be accurate, objective, timely, complete, professional, and truthful. Documentation isn't something you do because your instructor required it. It isn't something that you do just because the computer has a box that you can check, and it isn't busy work. Documentation is part of patient care. It communicates, it creates a permanent record, it demonstrates accountability, it supports quality and reimbursement, it protects patients' confidentiality, and it can serve as a legal evidence. So next time you sit down at the computer and think, "I don't really have to chart this," I want you to change that thought and instead say, "I need to communicate what happened to my patient's health care team." Because that's really what you're doing. You're telling the story of your patient's care. As an LPN, that story needs to be accurate. If you provide care, document the care. If you assess it, document it. If changes have happened, document it. If you've administered something, document it. And most importantly, document the truth. That is one of the foundations of safe nursing practice. So thank you again for joining me for another episode of Nursing Together. Until next time, keep learning, keep asking questions, keep thinking critically, and remember, good nurses provide excellent care. Excellent nurses provide excellent care and document it