Introduction
Documentation is a vital component of safe, ethical, and effective nursing practice regardless of whether it is documented in paper-based or electronic form.
Definition
Documentation is the permanent recording of information properly identified as to time, place, and circumstance.
Attribution documentation is the written legal record of all pertinent interactions with the patient-assessing, diagnosing, implementing, and evaluating.
Uses
- Written records are kept to meet legal, regulatory, managed care, and billing requirements.
- In the event of a malpractice lawsuit, the medical record is also used as evidence of the care provided.
Purposes
- Effective communication.
- Practice and legal standards.
- Reimbursement.
- Education.
- Research.
- Nursing audit.
Electronic Medical Records (EMR)
All hospitals should be charting on an EMR system
- To improve patient’s health status.
- To reduce errors.
- To improve patient safety.
- For evidence-based recording.
The emergency documentation includes information relevant to the patient’s complaint including the subjective, objective, assessment, and plan (SOAP) portions.
The four key elements are the subjective section, objective section, assessment section, and plan section.
Subjective section
- The patient’s presenting/chief complaints.
- The history of present illness-the main aspects of a symptom of a chief complaint (such as pain): Onset, provocation, quality, radiation, severity, and time (OPQRST), location, alleviating factors, and aggravating factors.
- Over-the-counter and prescription medications, and any medication allergies.
- For patients with more chronic problems, compliance with any medications or medication side effects, current symptoms or complications, multiorgan failure, and any healthcare needs related to the chronic illness.
Objective section
- Includes everything observed or measured during the interaction with the patient.
- Uses standard medical language to report the vital signs, general appearance, relevant physical examination, and any laboratory or imaging results.
- Thorough physical examination documentation.
- Results of any laboratory or radiological studies ordered during the visit.
Assessment section
- Summary statement: Concise summary of the chief complaint along with main elements of the subjective and objective sections.
- Problem list: Details of all problems.
- Discussion of differential diagnosis: Brief account of a probable differential diagnosis for each acute problem on the problem list.
Plan section
- Diagnostic recommendations: Observation, laboratory tests, radiological imaging, ECGs, or other diagnostic procedures.
- Treatment options: Therapeutic procedures.
- Follow-up plans: Clearing follow-up plan for future care.
Legal Documents
- Consent
It is usually done by the physician staff (but witnessed by a registered nurse). Consent should indicate that the patient understands the risks, benefits, and alternatives to the proposed treatment. - Medicolegal case (MLC)
This applies to any case of injury or medical condition in which law enforcement agencies seek to investigate and fix the responsibility regarding the said injury or medical condition. MLC is a medical or clinical case with legal implications. - Against medical advice (AMA)
Documentation of an AMA, which refers to a patient’s or his or her family’s choice to leave the hospital before the treating physician recommends discharge, must include a discussion and the patient’s understanding of the risks of leaving (“up to and including death”) before the formal discharge.
General Guidelines for Documentation
Do’s in Documentation
- Write clearly and legibly.
- Clearly demonstrate the chronology of treatment.
- Use “Late Entry” when appropriate.
- Every entry must be dated, timed, and signed.
- Time must be mentioned with signatures.
- All charting must be accurate and factual.
Don’ts in Documentation
- Avoid vague/incomplete statements, for example, “Doctor informed.”
- State the name of the physician.
- State personal opinion.
- Only state what is “observed.”
- Do not falsify or make up information.
- Avoid overwriting, duplication, errors, and illegible writing.
Nurse’s Responsibilities
- Understanding the importance of complete and accurate documentation.
- Documentation of clinically relevant aspects of the patient encounter including laboratory, radiological, and other testing results.
- Efficiency in the patient encounter continuum.
- Documenting thinking and adherence to the standard of care.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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