4.6 Documentation

Using Technology to Access Information

Most patient information in acute care, long-term care, and other clinical settings is now electronic and uses intranet technology for secure access by providers, nurses, and other health care team members to maintain patient confidentiality. Intranet refers to a private computer network within an institution. An electronic health record (EHR) is a real-time, patient-centered record that makes information available instantly and securely to authorized users.^[1] Computers used to access an EHR can be found in patient rooms, on wheeled carts, in workstations, or even on handheld devices. See Figure 4.2^[2] for an image of a nurse documenting in an EHR.

The EHR for each patient contains a great deal of information. The most frequent pieces of information that nurses access include the following:

• History and Physical (H&P): A history and physical (H&P) is a specific type of documentation created by the health care provider when the patient is admitted to the facility. An H&P includes important information about the patient’s current status, medical history, and the treatment plan in a concise format that is helpful for the nurse to review. Information typically includes the reason for admission, health history, surgical history, allergies, current medications, physical examination findings, medical diagnoses, and the treatment plan.
• Provider orders: This section includes the prescriptions, or medical orders, that the nurse must legally implement or appropriately communicate according to agency policy if not implemented.
• Medication Administration Records (MARs): Medications are charted through electronic medication administration records (MARs). These records interface the medication orders from providers with pharmacists and are also the location where nurses document medications that have been administered.
• Treatment Administration Records (TARs): In many facilities, treatments such as wound care are documented on a treatment administration record.
• Laboratory results: This section includes results from blood work and other tests performed in the lab.
• Diagnostic test results: This section includes results from diagnostic tests ordered by the provider, such as X-rays, ultrasounds, etc.
• Progress notes: This section contains notes created by nurses and other health care providers regarding patient care. It is helpful for the nurse to review daily progress notes by all team members to ensure continuity of care.

Legal Documentation

Nurses and health care team members are legally required to document care provided to patients. Any type of documentation in the EHR is considered a legal document. In a court of law, it is generally viewed that, “If it wasn’t documented, it wasn’t done.”  Other documentation guidelines include the following:

• Documentation should be objective, factual, and professional. Only document what you personally assessed, observed, or performed.
• Proper medical terminology, grammar, and spelling should be used.
• All types of documentation must include the date, time, and signature of the person documenting.
• Abbreviations should be avoided in legal documentation.
• Documentation must be completed in an accurate and timely manner after the task is performed. Do not document in advance of completing a task.
• Assessments, interventions, medications, or treatments that were not completed should never be charted as completed. This is considered falsification and can present serious legal ramifications for the nurse and the health care facility.
• When using paper documentation, avoid leaving blank lines to prevent others from adding to your documentation. In the event of a charting error, draw a single line through the error and write, “mistaken entry” above the line with your initials. Errors should never be erased, scribbled out, or covered with white-out.
• If electronic documentation is charted in error, it should be corrected with the details of the error and the correction noted in the background should the need arise to review the documentation.

Documentation is used for many purposes. It is used to ensure continuity of care across health care team members and across shifts; monitor standards of care for quality assurance activities; and provide information for reimbursement purposes by insurance companies, Medicare, and Medicaid. Documentation may also be used for research purposes or, in some instances, for legal concerns in a court of law.

Documentation by nurses includes recording patient assessments, writing progress notes, and creating or addressing information included in nursing care plans.  More specific documentation and types will be integrated throughout the clinical experiences.

Attribution