Standards and methods of documentation: Nursing

Nurse Steve is a nurse working on a medical unit. He calls the healthcare provider to address a client’s pain, and the healthcare provider gives Nurse Steve an order over the phone, saying “You can put in a prescription for 30 mg codeine PO every 4 hours.” Nurse Steve reads the order back aloud and the healthcare provider confirms it.

When Nurse Steve goes to enter the order into the computer system, he receives an alert from the pharmacy that the client has an allergy to codeine.

Nurse Steve calls the healthcare provider back and informs them of the allergy alert. The healthcare provider tells Nurse Steve, “You can override that alert. They have taken this medication before and tolerated it fine.”

After ending the call, Nurse Steve enters the client’s room to inquire about this documented allergy. The client reports that the first time she took codeine, she felt nauseous and vomited, so the nurse documented it as an allergy. But in reality, it was a side effect of taking the medication on an empty stomach. The client reports that she has taken codeine at home as prescribed without any allergic reactions. Nurse Steve will use what he knows about documentation to ensure there’s an accurate account of this clinical decision in the health record.

Documentation is a communication strategy that allows members of the healthcare team to provide a written account of client information, such as assessments, interventions and responses. Documentation can be handwritten or electronically stored within the health record, which provides a real-time account of medical and nursing care.

Okay, accurate documentation in the health record is necessary to communicate with all members of the healthcare team regarding the client’s status, plan, and care. It is also crucial for several other reasons such as legal protection, facility reimbursement and quality improvement, or QI.

First, documentation is one of the best defenses for litigation in healthcare, and by documenting nursing care you can limit legal liability by showing evidence that you followed the standards of practice. Remember the common saying, “If you didn’t document it, it didn’t happen.” This means that documenting the care you provide is just as crucial as providing safe and effective care.

For example, if a client develops an extravasation from an IV medication and the nurse didn’t document the assessments they performed, the nurse could be liable for this preventable complication.

Next, documentation is also crucial for financial reimbursement for healthcare services. Insurance companies look at the health record to determine the amount of payment healthcare facilities receive for providing client care. Nursing documentation that includes a clear description of a client’s treatments, prescriptions, and the supplies used helps to expedite timely and appropriate reimbursement.

If Nurse Steve administers the codeine but forgets to document a pain reassessment later on, the hospital may lose reimbursement for failing to follow the quality standards for the treatment and assessment of acute pain. The health record can also generate data for QI since it allows for clinicians to track and evaluate client care over time.

For example, if nursing documentation reflects that clients who are out of bed more often develop fewer postoperative infections, this could prompt a QI project aimed at increasing client ambulation.

Let's learn about the different methods of documentation. Although each healthcare facility chooses their own type of documentation, a few common examples are client assessment data, progress notes, and charting by exception. Client assessment data allows for nurses to quickly and concisely enter all of a client’s normal and abnormal assessment information, such as skin appearance and breath sounds, which can be viewed by all members of the healthcare team.