by Joyce Good Henderson

Created on: April 24, 2009

Nursing: the importance of documentation and charting

One of a nurse's greatest fears is realized: you receive a subpoena concerning the care you gave a patient a year ago. Would you be able to remember the details of that patient's care?

Nurses have always faced the challenge of reconciling documentation with quality patient care. Some would argue that paperwork interferes with time spent caring for patients. However, with proper documentation on the patient's chart, you would have the information you need to ensure quality care and to defend that care in court, should that be necessary.

Effective documentation provides a record demonstrating and giving proof of individualized nursing care and the patient's response to that care (outcome). Documentation provides:

Improved quality of care due to increased communication between patient and caregivers;

Baseline patient information;

Accessible details in the event litigation occurs;

Record of professional accountability;

Data for evaluation of performance and quality of care;

Determination that standards of care have been met.

Documentation may take three different forms: written records, observation and reports. Written records should address the elements of the nursing process: nursing assessment, planning, implementation and evaluation.

The acronym SOAPIE provides an ideal format for a narrative patient record. SOAPIE, a systematic approach, details a goaloriented nursing care plan in a note. The nursing process begins with assessment which is:

Subjective reports what the patient says;

Objective records what the nurse observes;

Analysis identifies a nursing diagnosis, the patient's actual or potential problems,

and the expected physical or behavioral response.

Plan describes nursing interventions;

Implementation records how those actions were carried out;

Evaluation reports the actual patient outcome or response.

In addition to written records, documentation may involve observation, which occurs when another person supervises a nursing intervention, for example, during a process audit. This data is of limited value, however, because it is dependent on the judgment, values and skills of the observer, and it is not as easily retrieved as patient records. Therefore, when setting up quality assurance studies, consider the value of information obtained through observation.

Reports, such as changeofshift reports, relief reports, and patient transfer reports, may be written or oral. The nurse may communicate pertinent patient care information even when it is not part of the patient's record. Examples of written reports are: standard nursing care plans, procedure or preference cards, logs and incident reports. As with observation, this data may not be retrievable or objective.

Nurses may consider documentation their foe, because it steals time from direct patient care, or their friend, giving direction and ensuring quality in patient care. The time and effort you devote to the patient's record allows the documentation to be pertinent, uptodate, correct and complete. Balance the time spent against your vulnerability to a charge that lack of documentation means your were either unaware of an incident or did not take appropriate action. In today's litigious culture, effective and complete documentation is a matter of professional survival.

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