Nursing Documentation Articles




	Articles
	Nursing documentation must make sense, must have meaning, and must communicate. Effect of Poor Documentation Has poor documentation impacted patient care in your facility? Has the use of bad abbreviations wasted time and detracted from patient care? (See the article Abbreviations: A Shortcut to Disaster on this page for more on the topic.) Has your organizations' bottom line been affected because equipment, medication, or treatments were not properly documented? If you completed a patient assessment and then looked at a previous assessment, could you make a better decision about what to do next for the patient? If the previous assessment was properly documented, the answer would be yes. But if the previous documentation was incomplete, then the employee would have a hard time making a good decision! Documentation does impact the quality of care given. Maybe the reason for the complaint that "no one reads our charts" is because nurses do not say what needs to be said! Documentation must be accurate, clear, concise, complete, and timely. Speed is of the essence when working in healthcare, but accuracy and completeness are imperative when documenting. Do not let the patient’s health be compromised by worrying about the speed; make sure it gets done right the first time. Documentation must have meaning today, tomorrow, and in the unforeseen future. One of the difficulties with documentation is that we never know when what we document will be needed. You want to make sure the right information gets documented and that documentation is done correctly. Nursing documentation is important and not just for legal purposes. The results and benefits of nursing documentation are greater than the sum of the tasks themselves. It isn’t an easy task, but it is necessary and it is a way of giving high-quality patient care. The lack of proper documentation can negatively impact patient care and can ultimately cause other problems. This was shown with nursing research done by Paice, et al., who found that pain management of surgical oncology patients was inadequate. They stated that the lack of documentation they found in their study led to a "...lack of consistent care and the inability to evaluate the effectiveness of pain therapies."¹ Their research becomes even more important in light of new consideration of pain as the fifth vital sign and JCAHO’s emphasis on pain management this year. Continued	Abbreviations: A Shortcut to Disaster This article poses some interesting thoughts for your staff and the use of abbreviations in their documentation. Are they hurting the patient, themselves, and your organization? Are you putting your patient at risk by using abbreviations? Are you putting your career at risk by using abbreviations? Nurses are supposed to be communicators, especially when documenting patient information. If what we write does not communicate, then we have failed in our professional and legal responsibilities. Furthermore, we have failed our patient and our employer, thereby putting all at risk. When documenting, it is imperative that we do not put our patients’ lives at risk because of the methods we use for the task. These methods include the use of abbreviations. The indiscriminate use of abbreviations can be extremely dangerous to the patient and the nurse and a major waste of time. Abbreviations can be a total mystery to the reader. If a doctor wrote "Patient may get up AFAWG," would he have communicated with you? How much time would you have to spend trying to figure out what he meant? If you and two other nurses looked at this order for 90 seconds each, four and a half minutes of patient care time would have been wasted. Plus you probably still would not have the correct answer. Abbreviations are easily confused. Patients are still being overdosed with insulin and heparin because people use "u" for units. Another critical error can occur with the use of "mg" for "microgram," which has been misinterpreted to mean "mg" for "milligrams." Any of these situations could lead to a serious medication error and catastrophic results for the patient. How would you like to write the incident report on the newborn who received ten units of insulin instead of the one unit he was suppose to receive? This type of error automatically multiplies the dosage by a factor of ten. Next, abbreviations that start out as time-savers can end up as time-wasters. As nurses, we often use abbreviations to speed documentation. But does the reader get our intended message? Ask three nurses what "pt voided qs" means. One might tell you "voiding quantity sufficient" and another one might say "voiding every shift." Try this abbreviation: "MSO4." Did you say morphine or magnesium? I have received both answers in every class where I asked the question. The differences in these interpretations could have devastating consequences. Continued
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