ISSUES IN NURSING DOCUMENTATION
The purpose of documentation is to clearly communicate the condition of the patient as well as the assessment, planning, implementation, and evaluation work of nursing.
It is a continual and ongoing process that reflects the changing needs and conditions of the patient.
Documentation is the critical and sometimes only form of communication among all health care providers about the current condition of a patient.
ISSUES IN NURSING DOCUMENTATION
Currently patient care documentation is found in a variety of forms and formats, handwritten and computerized.
Written documentation systems have been developed to assist clinicians to produce accurate and comprehensive documentation. Examples include the following: (a) problem-intervention-evaluation charting (PIE); (b) subjective-objective-assessment-plan charting (SOAP); (c) problem-oriented medical record charting (POMR); and (d) charting by exception formats, outcome-based charting; and critical pathways ( ).
Checklists for exception charting to address the time restraints have been implemented as documentation requirements for regulatory compliance increase.
At times, nurses shortcut documentation because of time constraints or limitations of these forms at the expense of complete charting.
ISSUES IN NURSING DOCUMENTATION
As patient care becomes increasingly complex, the importance of timely and accurate documentation becomes increasingly important.
Delays, omissions, and errors in documentation may result in delays or errors in assessments, interventions, treatments, procedures, and medication administration.
These errors often create a cascade of events that may negatively impact patient care or patient outcome.
Computerized documentation systems
Computerized documentation systems are more than automation of existing paper forms.
State-of-the-art documentation systems are designed to more closely reflect the flow of patient care processes in an orderly way and to increase patient safety within the available features and design.
Computerized clinical documentation systems that support functional requirements contribute significantly to patient safety and caregiver effectiveness.
Computerized documentation systems
Safe nursing practice is supported in the following ways with an electronic record that includes:
Design of documentation systems that more closely reflect actual work processes and patient throughput, supporting clinician assessments and work organization
Integration of physician order entry, medication administration, and clinician documentation systems
Inclusion of a framework that encompasses nursing knowledge functions as a cognitive map for clinicians (nurses handle large amounts of data and often experience overload and stress; also provides professional support in making complex clinical decisions) and increases efficiency ( )
Computerized documentation systems
Integration of standards-based organizing frameworks such as Nursing Interventions (NIC), Nursing Outcomes (NOC), and North American Nursing Diagnosis Association (NANDA)
Use of a complex and comprehensive database for patient and nursing research
Inclusion of alerts, popups, and protocols to guide caregivers in both care processes and documentation
Computerized documentation systems
Specific outcomes from computerized documentation that have an impact on patient safety and decrease the potential for practice breakdown include:
Elimination of illegibility
Minimized duplication
Improved response time to patient requests
Computerized documentation systems
Specific outcomes from computerized documentation that have an impact on patient safety and decrease the potential for practice breakdown include:
Improved documentation completeness
Increased compliance with regulatory requirements (e.g., assessments for pain level, skin integrity, and fall risk)
Simultaneous, real-time access to up-to-date patient data for multiple clinicians
Computerized documentation systems
Issues with computerized documentation:
If there are rigid rules for documenting the administration of medications within one-half hour of administration, and the patient-to-nurse ratio is too high, the nurse may be tempted to document before actually administering the medication.
This sets the patient up for undetected “missed doses” of medication.
If the workflow and patient care record are poorly designed, requiring excessive amounts of time for access, then nurses may not have a chance to document their assessments and treatments in a timely manner.
Nondocumented therapies place patients at great risk for second doses of narcotics, sedatives, or other medications.
Computerized documentation systems
Issues with computerized documentation:
The down side of the extensive requirements for documentation in today's complex hospitals is that the nurse can spend from 13% to 28% of his or her time in patient care documentation, and this reduction in the nurses' availability to provide direct patient care has been shown to diminish patient safety ( ; ; ).
HISTORICAL CASE STUDY
Discuss the HISTORICAL CASE STUDY described on Ebook: (Page 50)
HISTORICAL CASE STUDY #1: Late and Later Documentation PRACTICE BREAKDOWN IN DOCUMENTATION
References
G.M. Keenan, E. Yakel, D. Tschannen, M. Mandeville: Documentation and the nurse care planning process. In R. Hughes (Ed.): Patient safety and quality: A handbook for nurses. 2008, Agency for Healthcare Policy and Research, Rockville, MD, 1–33, Available online at , Accessed 10-30-2008.
G. von Krogh, C. Dale, D. Naden: A framework for integrating NANDA, NIC, and NOC terminology in electronic patient records. Journal of Nursing Scholarship. 37(3), 2005, 275–281.
In A. Page (Ed.): Keeping patients safe: Transforming the work environment of nurses. Committee on the Work Environment for Nurses and Patient Safety, Institute of Medicine 2004, The National Academies Press, Washington, DC.
L. Korst, A. Eusebio-Angeja, T. Chamorrow, C. Aydin, K. Gregory: Nursing documentation time during implementation of an electronic medical record. Journal of the American Medical Association. 33(1), 2003, 24–30.
M. Pabst, J. Scherubel, A. Minnick: The impact of computerized documentation on nurses' use of time. Computers in Nursing. 14(1), 1996, 25–30.
S. Meiner: In Nursing documentation: Legal focus across practice settings. 1999, Sage, Thousand Oaks, CA.
