I had the opportunity to sit around a table with several nurses last week to discuss documentation. I asked the nurses why we documented at all. I wasn’t surprised at the responses I received but their answers told a story I think we all need to hear. Before you read further, ask yourself what the most important aspect of documentation is.
If you answered that, ‘if you didn’t chart it, you didn’t do it’, you would be wrong. I understand the logic of this response but it is completely inadequate. If you don’t believe me, try giving the patient the wrong medication that causes an anaphylactic reaction. You will not be relieved of your role in the death of a patient if you simply elect not to chart that you gave the mediation. But there are many occasions where incomplete documentation will result in a lack of evidence that you actually performed certain tasks. This is not good.
A number of nurses spoke of the old CYA strategy. Lawsuits are a very real and present danger to anyone in health care. But, make no mistake. Impeccable documentation will not spare you from the pain and agony of a lawsuit. However, if you want to walk away with your license intact and facing no jail time, clean documentation certainly won’t hurt. Considering none of the nurses at the table that day had ever actually been sued, I’m wondering if that is the best reason to chart.
Surveys are important. A good survey result in your agency having an unencumbered license for another year and a bad survey results in some painful problems for an agency. In the absence of blatant fraud or negligent care, a survey usually doesn’t result in a threat to your agency’s license but good documentation can make your life easier a year at a time unless you just like surveyors.
Finally I heard that Medicare and other payor sources require certain elements of good documentation in order to pay bills. This much is true and violating payment criteria for any of your payor sources can result in a world of hurt for your agency. Imagine not getting your paycheck one day. Now imagine the entire agency not getting a paycheck. As nurses we don’t like to think about money and patient care in the same train of thought but if you want to make your house note this month, it might be an idea to do so.
But…… even cash is not a good enough reason for most of us, including myself, to pay much attention to documentation.
The most compelling reason that I can think of to document accurately and timely is to facilitate coordination of care. Okay, okay – that sounds like I’ve been spending too much time reading regulatory manuals. Try this: If you want your patient to receive good care, write good notes so everyone knows what it going on. If you don’t, you put your patient may wind up sick or dead.
That’s all there is to it. And I think it’s enough.