Why Do I Have to Document?

Why Do I Have to Document?

©2008 Kathy Quan RN BSN   All Rights Reserved

Documentation is key to communication with other members of the health care team including other nurses, physicians, therapists, aides, dietitians, pharmacists, etc. It is also vital to improved patient outcomes and the quality of patient care as well as continuity of care.

Nurses often complain that documentation takes away from actual caring for patients and they resent having to do so much paperwork. Without documentation however, patient care and outcomes can be completely compromised and the Nursing Process weakened.

Here's an Example

Assume for a moment that you only had to rely on what the nurse (Carol) told you during report or rounds. She's distracted and in a hurry because she's leaving after work for a 3-day cruise. Carol forgot to tell you that your patient, Mrs. A, developed a rash all over her body when given her antibiotic this morning and the medication has been changed.

Carol also forgot to tell you that the dressing on her abdomen needs to be changed soon because she didn't get to it today and it should be changed BID. And, oh yes, Carol also neglected to tell you that Mrs A. patient fell in the bathroom and bumped her head a few hours ago, but had no immediate ill effects. The doctor was called and a message left with his nurse. He'll be in for rounds at 6 PM.

You enter Mrs. A's room and find that she is feeling nauseous and dizzy and has a headache. You instruct her to try to lay still and rest. You check her dressing and find it saturated. Mrs. A tells you she is “still a bit itchy.” [Itchy from what?] Mrs. A doesn't know, but she's been itchy all day and she told the day nurse (Carol) about it. She has a rash all over her abdomen. It's pale pink, but is it fading or just budding? Is it related to something such as a medication?

Immediate Jeopardy?

These are all new findings and need to be reported to the doctor. He's very perturbed with you that you don't know about the fall and how long she has had her rash symptoms. He can't understand why you don't know about her reaction to the antibiotic this morning. How long has she had the rash? You can't tell him when the last dressing change was done either, but you assume it was in the morning, so this seems to be a significant increase in drainage.

You can't reach Carol, she's left for her 3-day cruise. No one from the previous shift is still around. The patient, Mrs. A, is forgetful and becoming somewhat confused. She knows who she is and where she is, but she thinks it's morning and she just woke up. Mrs. A also thinks it's Tuesday and it's Friday. Has she been confused for awhile or is this also new?

You haven't worked in three days and Mrs. A is new to you. None of your team today knows her. Wouldn't a chart be helpful? Documentation does indeed take time, but it is so very important to patient care and continuity.

Although this is an example from hospital care, something similar could happen in the home care environment as well if there is not adequate communication between disciplines and colleagues. 




©2007-present by Kathy Quan RN BSN PHN, all rights reserved. No portion of this document may be used in any format without written permission. Email me. Reprints may be purchased in single or bulk quantities.

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