Is Documentation Important?
Mary Knight, RN, CMAS® Vice-President
How many times have we heard the word “documentation”? Documentation must be objective, legible, accurate, clear, concise and complete. This being said, documentation has meaning today, tomorrow and in the future. We never know when what we document will be needed. If you are called to testify regarding a specific patient that was under your care, will you be able to recall by reading your documentation?
Documentation is important and not just for legal purposes. It is a necessary way of giving the highest quality care to the patient. The lack of proper documentation can negatively impact patient care and can ultimately cause other problems. If what we document does not communicate, we failed in our professional and legal responsibilities. In other words, we failed our patient. Documentation is not separate from care and it is not optional.
Some facilities use charting by exception indicating findings are within defined limits unless otherwise noted. As a nurse, you need to know these defined limits. Charting by exception requires selecting abnormal and writing applicable text and can be more prone to legal interpretation of a breach in standards in nursing care.
Documentation is critical; failure to chart can be hard to defend. You may be called to testify long after the event. I know this from personal experience. I testified in a three hour deposition regarding a patient for whom I provided care two years earlier. Luckily, the nursing school I attended stressed the importance of accurate documentation. I was able to recall all pertinent information regarding my patient’s care by referring to my documentation. I later learned that the case had a favorable outcome due to my detailed charting.
A lawyer will rely on available documentation to establish whether the care provided by the nurse was reasonable and prudent. Something that is not documented did not occur.
Here are some funny lines that I came across on the Internet:
- Patient has chest pains if she lies on her left side for over a year.
- On the second day, the knee was better, on the third day, it had completely disappeared.
- While in the emergency department, she was examined, x-rated and sent home.
- Patient was alert and unresponsive.
- She is numb from her toes down.
- She stated that she had been constipated for most of her life until 1989, when she got a divorce.
- Patient complains of indigestion since last night when he ate a stake.
- The patient lives at home with his mother, father and pet turtle, who is presently enrolled in day care three times a week.
- Patient was in his usual state of health until his airplane ran out of gas and crashed.
- Discharge status: alive, but without permission.
Just remember, “Care not documented is care not done”.
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