Documentation is the written evidence of every interaction between patients and their families and the caregiving team. The goal of documentation is to tell the story of the patient’s journey through the system, their responses to the treatments received, and the status of their health and wellbeing.
Why do we document?
There are many reasons why we document in healthcare from legal to regulatory and everything in between. The ultimate goal is to ensure all clinicians touching the patient can have a thorough understanding of the patient, their previous and current health status, and where they are in their treatment when verbal reports or handoff is unavailable. State and federal laws, licensing boards, health insurers, as well as accrediting bodies dictate the way healthcare documents. The type, frequency, and minimal content of documentation are determined by all of these agencies and clinicians must document to meet them.
Patient Safety and Documentation
Patient safety is impacted by the quality of the documentation. When reviewing charts involved in claims, documentation can be broken into three main categories: lack or inadequate, content, and mechanics. The most frequent and costly mistake is not documenting or not documenting enough. Particular areas of concern are past medical and surgical history, adverse events, details communication and discussion such as informed consent or plan of care, and clinical rationale or decision making. In the age of the electronic medical record, content issues such as altered documentation and the metadata behind the scenes that reveal alterations, inconsistency, and the mechanics of when documentation occurs has been come more apparent. Understanding that what you write or do not write can negatively impact patient outcomes can help to improve your documentation.
How should we document?
Good documentation starts with you. Remember you are telling the patient’s healthcare story. Every contact between a patient and a caregiver should be noted in the record using either prebuilt checklists or a narrative. Document concisely, relaying all of the facts. Note observations and interactions with other caregivers such as verbal reports, telephone orders, or notification of concerns. Ensure the documentation is complete and closes the communication loop. For example, when documenting a call for an as needed nebulizer you should include the reason you called which can be relayed through the airway assessment and current set of vital signs. Next, there should be a note of the treatment rendered to include what type of treatment was given, the patient status during the treatment, and whether the treatment was completed. Then, a reassessment of the patient as well as a new set of vital signs and any further follow up indicated. Lastly, a note regarding the effectiveness of the treatment and any notification or communication among providers regarding this point of care. Remember, timely and accurate information builds the foundation of good documentation.
Whether you are documenting narratively or by using prebuilt picklists and check boxes, telling the full story is the goal. There are many tools to help you improve your documentation. SBAR, a pneumonic for situation, background, assessment, and requests or recommendations or reassessment is one such tool. Another method is SOAPIER: subjective data, objective data, assessment, plan, intervention(s), evaluation of response, revision in the plan of care. PIE: problem, intervention, and evaluation, is also a quick and effective way to think about event documentation.
Documentation is not a choice or a task, it is a legal requirement. Complete, concise, and timely documentation builds the full picture of a patient’s care. Documentation can be improved using tools such as SBAR, PIE, or SOAPIER. Improved documentation leads to improved patient care and quality outcomes.