I think we’d all like our roles as nurses a whole lot better if we didn’t have to document. I hear nurses say all the time that they spend more time DOCUMENTING than taking care of patients. And sometimes, I agree.
But documentation is an important part of what we do. Why? Well, documentation helps providers identify problems and make appropriate treatment decisions; allows you to take credit for the work you do; ensures that you’re practicing according to standards of care; and helps your organization get the maximum reimbursement for your hard work!!
However, documentation can also be used against a nurse – especially when patients have bad outcomes.
Some nurses end up losing their licenses, their jobs, and may find themselves defending their practice in a court of law because of their documentation or lack of it.
They say if you didn’t document – you didn’t do it. I’ll kick it up a notch. I heard my friend and colleague Linda Willette say, “If you didn’t document – you can’t PROVE you did it.” And she’s right!
To protect yourself, your job and your license, NEVER EVER...
· Chart in advance – this is a red flag for lawyers. The computer captures everything and time stamps when you actually documented versus the time you manually entered. If you’re going to “lie” about the timing of care, what else might you be lying about?
· Document that you did something when you didn’t – this is considered falsifying a record. For example, if your colleagues asks you to witness an opioid waste but you really didn’t witness it, don’t document that you did!! You could be held responsible along with that nurse.
· Vent your frustrations in the patient’s medical record – not only will a lawyer jump all over this, but you may also receive disciplinary action from your employer! A nurse once wrote, “Patient going into shock but could not reach Dr. Rossi as usual.” Who is liable here? Both the nurse AND Dr. Rossi!
Not to worry…effective documentation is a skill that can be learned!! It just takes a bit of your time and commitment to ensuring you documenting according to your organization’s policies. Remember, ignorance is not a defense!
I hope these tips help. Thanks so much for choosing to become a nurse. I'm cheering for your success!