Nurses: What Is the Most Important Documentation Advice?

Carolyn Buppert, NP, JD

Disclosures

August 21, 2012

Question

As nurses, we are told that our documentation is important and "If it's not documented, it wasn't done." Do you have any overall advice on what should and should not go into the patient's chart?

Response from Carolyn Buppert, NP, JD
Attorney, Law Office of Carolyn Buppert PC, Bethesda, Maryland

Here are 5 goals to consider when writing your notes:

1. Describe behavior or write down statements made by patients or family members, rather than characterizing the behavior or statement. For example, write "Patient smiling during rounds, asking staff about their evenings" rather than "In good spirits." Write "Patient's daughter in today. She said, 'Leave the room. We're busy,' rather than "Patient's daughter rude today."

Why? Because the description or statement gives the clinician following you a clearer picture of the situation than a phrase in which you make a judgment. No one needs to guess about what "in good spirits" or "rude" means. Patients can obtain their records, and a nurse who makes a judgment about the manners of family could complicate a case, should the patient have a negative outcome.

If a clinician documents that the patient is not interested in his or her surroundings, subsequent clinicians can ask the appropriate questions to evaluate whether there has been a change in mood or level of consciousness. Finally, if the records become part of a court case, descriptions of behavior or quoted statements are going to lend strength to the defense because they are more credible than personal impressions.

2. Write as if your next promotion depends on this note. That is, check your spelling and grammar. Don't use slang.

3. As a rule, use sentences -- noun, verb, and adjective. For example: Rather than "Coughed," write "Patient coughing productively during rounds." Rather than "Progressive hypotension," write "Blood pressure dropped from 110/60 at 0800 to 100/50 at 0815 to 80/40 at 0845."

4. Document any recommendations that you make that the patient outright rejects, and document the patient's words. That shows that you did your job by educating the patient about the need for a treatment, medication, precautions, or to cease an unhealthy habit, but the patient rejected your advice. If the patient has a bad outcome and sues you and the hospital, the defense will be in a better position because you documented that you provided sound advice, but the patient rejected it.

5. When documenting an event for an incident or event report, describe the patient's condition; interventions and the patient's response to them; and what you observed, if anything, but don't speculate on the cause of the event. The event team will use the information that you provide as well as information others provide to determine the cause. Because medical records are "discoverable" -- that is, can be accessed by someone who is suing the practice or facility -- it is best to limit your entries to descriptions of observations and services provided, rather than making conclusions about causes of mishaps.

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