nursing documentation

Nursing DocumentationNursing Documentation

Author:Meredith Scannell, RN, CNM, MSN, MPH

“If it wasn’t charted, it wasn't done”

DocumentationDocumentation

• Nurses have a duty to maintain complete and accurate recording of all the care thy provide.

• Nurses working in specialty areas have greater risk for litigation exposure.

• Complexities of care patients require more documentation


• The medical record is a legal document required by state laws and regulations.

• Medical records are scrutinized by members of the litigation team.

• Considered as important as testimony in courtroom.

• Most important piece of evidence in a lawsuit alleging negligent practice.


• May be handwritten

• May be electronic

• Combination


• Other uses for medical records:-Education- Research- Substantiate reimbursement/insurance

claims.

• Can be used as legal evidence in litigation cases to establish if standard of care was met.


• Nurses are considered clinicians• Role is not limited in the care of patients and in

past years there has been a paradigm shift.• Profession judgment• Highly skilled• Educated professions• Care delivered based on making clinical

decisions based on assessments.


• Risk exposure includes• Assessment• Communication a change in patient

condition• Initial and subsequent nursing diagnosis• Interpretation of diagnostic findings• Treatments• Changes in treatment plans• Medication adminstration and dosing


• Purposes• Ensuring quality of care through

communication• Legal evidence of the continuity of care• Legal evidence of outcome of care• Assist in establish stands of practice• Provide a database for trending outcomes

Safe DocumentationSafe Documentation

• Follow hospital/agency policy

• Failure to follow policy can resultinconsistencies and appear non-credible in a court of law.

• Follow policies in how to make late entries.

““The palest ink is better The palest ink is better than the strongest than the strongest

memory”memory” -Chinese proverb-Chinese proverb


• Accuracy is critical• Contemporaneously “chart as you go• If ignored for too long, most likely forgotten• The higher the patient acuity the more frequent

documentation.• Document conversations with other healthcare

providers• Document nursing interventions before and

after notifying another healthcare provider


• Hospital/agency policy are not laws.

• Used as standards that should have been followed.

• Used as standards that were met.


• Documentation based on Standards of Practice for Registered Nurses when documenting information.

• Defined by state and federal laws.• Nurses Practice Acts: specific state requirements

that nurses shall be responsible and accountable• Specific Standards from Association of Women’s

Health, Obstetric and Neonatal Nurses, The National Association of Neonatal Nurses.

• Federal and state organizational standards; The Joint Commission, Centers for Disease Control


• Patients name is on every page

• Everything must be legible

• Late entry

• Maintain objectivity and not opinions


• Chronology of events • Date and time of entry• Patient history• Interventions• Observations• Outcomes• Patient and family responses• You signature and credentials


• Educational material given

• Understanding of educational material

• Referrals

• Consents

• Discharge plan

• Follow up

• Telephone calls (providers and family)

Documentation Don’tsDocumentation Don’ts

• Do not use the medical records as a battle Do not use the medical records as a battle groundground

• Do not blame and individual or departmentDo not blame and individual or department

• Limit finger pointing and focus on problem Limit finger pointing and focus on problem solvingsolving

• Do Do not chart opinions chart opinions

The EndThe End

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