I am Lion, Hear Me Roar — Take Pride in Your Documentation.
I am a Leo, so naturally I am in full support of this energy and this title. Rooaarr!! I give big lion energy whenever I need to, especially at work. I take pride in caring for patients, in my work, and in my documentation. No I'm not perfect at all my documentation, but I take the time to do my best and when quality documentation counts the most, I hit the mark. Documentation along with self confidence is a large part of a nurses job and is so very important. I cannot stress that enough, it does not matter if you have been a nurse for many years or if you're new to the field. In the nursing world we need to be adaptable to new normals and I encourage you to improve your documentation styles periodically along the way. Be loud, be proud of the work you do every day, chart it all and chart it well. You do not want to find out the hard way, meaning through a personal experience, as to why this is so important. You do not want to be called in by the legal team of your employer or called in for a deposition from years prior to defend your documentation. If it's not charted appropriately then it only happened in your reality and that's not enough.
I must say I am known by some for having the right words to say when it comes to documentation. An eloquent dance of professional descriptions you’ll learn to perfect over the years. You will figure out the best way to word certain things. You will build a wheelhouse of knowledge for your documentation. Your documentation throughout the shift is, in a way, the only proof of anything happening. If also done well, good documentation gives you, the nurse, a lot more credibility. Credibility with other providers reading the documentation and also caring for the patient. We all have licenses but a step further than that the documentation we provide is how entities get compensated and potentially forgo litigation while providing patient care. The more I understood my role and the big picture, the less personally frustrated I felt with things were out of my control at work.
I spoke briefly in another post about how nursing in the US is described as very monetary focused now as opposed to many years ago being more patient care focused. This is important to understand because your documentation specifically supports payment for a service. The licensed nursing services you are skilled to provide. If the documentation is not there to support the service provided then potentially the payment does not have to be made or can be asked to be paid back by your employer, not to even mention possible litigation our documentation comes up against over the length of our careers. It's mind boggling I'm sure. Involved care providers or lawyers pull charts and look through your documentation sometimes several years after you care for a patient. The odds of you remembering every little thing in your workshift, about one patient, five years later may be a little slim. You are counting on that documentation you wrote way back when to paint the picture of the patient care you provided. You are counting on your past self to be as accurate and as credible as possible. You want every time to count just in case. High quality documentation from the beginning will save you the troubles.
Not even going to lie, I often think of my work shift like a video game. A video game of me trying to collect all the coins, check all the boxes, do all the tasks. Is that absurd of me to say out loud?! I think when it’s crazy on your unit and there is a bunch of things going on, do you get overwhelmed or do you kick it into high gear?! I personally kick it into high gear. I need more ammunition, I need back up artillery, I need to power up, I need a hiding spot, I want to kill all the zombies and I want all the points. I am pretty competitive, not only because I have no biological siblings but also because I strive to do better everyday. That’s literally what I’m thinking. I'm a winner. I'm in competition with myself most of the time unlocking the next level of a better me. I try to check all the boxes off my list, I try get all my tasks done within a reasonable time, I try to chart in real time and I try to be a advocate for my patientse every time. By the end of all the craziness of the work shift, I get a major confidence boost when I am able to get it all done. I soon realize, dang I am good, getting better, getting faster — learning more for my wheelhouse of knowledge and all is well.
In my career, I’ve also had two really great lectures about documentation that have always stood out to me. One was in college, a graduate professor came to speak to us about the legal aspects of nursing, he was a grad school professor, nurse anesthesiologist and an attorney, wow. I will never forget that talk. Then another employer of mine had someone from the legal department or risk management come speak to the nurses about their documentation one day which was great. It was an awesome perspective to hear from the legal team when the department reviews a case. With that knowledge embedded in my mind and in my work, here are my top four points to remember about your nursing documentation.
ONLY CHART THE FACTS - Yes, will I chart "Patient laughed when offered to fill water pitcher this shift. Patient asked writer to grab a Diet Dr. Pepper can that was in a box by the wall. Patient reports they don't drink water." Absolutely, because that is what happened. If those are the facts and that's what happened then I am able to chart that. I can chart my efforts, I can chart the patients opposition. Another example is in a fall situation. The patient may say they tried to get up to go to the bathroom or to get something off the floor or they saw a snake on the ceiling. The specifics doesn't matter as long as that quote in the chart is what the patient said because often times later the story may change or the patient doesn't remember. Also along these lines would be advice to chart "normal" findings if they are abnormal for the patient. You can chart other normal findings of course but if the patient has a quirk or refusal definitely chart your efforts for example the patient did not want to change their clothes or wanted to wear shoes in the bed. If that is normal for the patient okay but they could still be at risk for skin breakdown etc. so make sure you as the care provider are documenting your efforts.
PAINT THE PICTURE - Since there are so many care providers involved in one patients care this is important. Other care providers are trying to follow up or find out what happened by reading the chart. Since they were not present in real time they are relying on your documentation to lead them to the image of the patient. Quality documentation includes very descriptive and objective turn of events. For example again in a fall situation. Poor documentation in the chart would be - Patient found on floor. No injuries noted. Better documentation would be - Patient observed on the floor next to bed. Patient reports having to go to the bathroom. No injuries noted. Best documentation would be - Patient observed on the floor next to bed sitting with legs stretched out in front. Patient back was leaning against the bed. Patient is alert with confusion. No apparent injuries noted. Able to move all extremities. Able to make needs known. Bed alarms activated and sounding but patient did not call staff for assistance. Non-skid socks in place. Patient last observed resting comfortably in bed. Assisted x 2 staff up off the floor and back into bed. No distress noted. MD and family notified. Will cont to monitor per protocols. This last example really painted the picture of what the patient was doing compared to the other examples. You don't your nurse manager to ask you again what happened because it was not clear in the documentation. Any behaviors leading up the fall or incident and what safety measures are in place is very important to include.
CHART IN REAL TIME - With most documentation on the computers now and electronic medical records, get in the habit of charting in real time. When something happens, chart it. When you take someone to the bathroom, chart it. It will help you in the long run. It helps with your credibility as a good nurse and will also help you keep track of time when you are in the patients room. We all have assessments and shift things that need to be charted at some point during the shift, then we also have other things that happen in between. If you chart all the in between things in real time, when you sit down later to chart the rest your mind will be at ease. I don't have to remember what I charted and didn't chart because you charted everything in real time. I can look and see when I charted that void earlier in the shift, other people can see when the patient voided last. If you chart the follow up vitals immediately, the charge nurse or other doctor potentially looking in the chart can also see the updated vital signs. In rehabilitation the documentation of intake and output is very important because you're trying to show the true burden of care for the patient. Documentation of the true burden of care for the patient then translates into the length of stay for rehabilitation, that could mean a few days less or a few days more to a patients stay.
DO NOTS - Some big not to do's are not to blame other team members or be defensive in your documentation. Do Not ever alter or destroy documentation, just go back and make a correction or edit. Make sure you are charting in the correct medical record. Do Not write specific coworker names in the documentation, I was always taught to refer to people by title. For example Charge Nurse, Nurse, Respiratory, MD etc.