The Importance of Good Documentation Practices


Posted to Nursing, Nursing Jobs, Uncategorized

Few things can save your job and reputation like your documentation. In instances where another clinician may question your judgment or activities, your documentation can indicate the date, time and other details necessary to prove that you acted in an appropriate manner.

Although nursing instructors attempt to teach proper and thorough documentation in nursing school, frequently new grads include either too much or not enough detail. A key to learning best documentation practices is to read other nurses’ notes. Although most facilities now use computerized charting due to new laws regarding the electronic medical record (EMR), you can check other nurses’ notes within your system. Additionally, some facilities (mostly nursing homes) still use paper charts.

Typically, all charting involves a lot of check-off boxes. In areas that require handwriting, remember that someone other than yourself may have to read your notes and that one day you may be called to testify as a witness. Your notes will serve to refresh your memory of events that may have occurred years earlier. Nurse attorney Carolyn Buppert, who has audited documentation for hospitals, states that poor handwriting can damage the credibility of the clinician. The more detailed and legible your note, the better your chance of a successful defense.

A nurse’s note should also support the reason and continued stay of the patient in the facility. If a patient is perceived to be too well, an insurance company may deny the claim. Good documentation saves facilities millions in denied claims. A nurse’s documentation justifies treatment plans, procedures and medications. When insurance companies analyze the patient’s record, parts of the claim may be denied to due to lack of supporting evidence of the patient’s illness. The facility must either eat those costs or attempt to collect them from the patient.

Abbreviations can be wonderful time savers when documenting a patient’s progress, but nurses should make certain they use the facility’s accepted abbreviations as well as avoiding abbreviations that the Joint Commission states are no longer acceptable. The latter list can change yearly.

One of the most neglected areas of documentation is follow-up after giving pain medication. The clinical standard for reassessment of pain level after giving a pain medication is within one hour. For a fast-acting IV push narcotic, reassessment may need to occur within a few minutes after administration, depending on the narcotic and the dosage. Lack of documented pain reassessment can leave the door open to future liability or simply a bad review if a patient says that the pain level was not well-managed.