As the saying goes in the health care profession, if it wasn’t documented, it didn’t happen. Whether you love it or hate it, well-written, timely, and accurate documentation is a vital and integral part of nursing practice.
Inaccurate documentation can cause medical errors that could temporarily cause harm or discomfort to patients. At the very worst, it can cause permanent disability or even death.
Regardless of where a nurse is in their career, it’s important to regularly review the following principles of nursing documentation and remember why it’s so important to get it right every time.
The Principles of Nursing Documentation
Nursing documentation is governed and regulated by numerous sources: state nurse practice acts, state and federal laws, your facility’s policies and procedures, and professional organizations, such as the American Nurses Association (ANA).
The ANA subsequently has defined six guiding principles for nursing documentation.
Nursing Documentation Principle 1: Documentation Characteristics
The first principle of nursing documentation concerns the physical characteristics of the content of any documentation.
As you chart your tasks and interactions throughout the day, ask yourself the following questions to check if your documentation is high quality:
- If the charting is handwritten, is it clear and easy to read?
- If the charting is electronic, is it clear and concise?
- Is it readily accessible, both now and in the future in case it needs to be checked, audited, or referenced for future care?
- Did you include all of the relevant information?
- Was it written during or shortly after performing the task or resolving the incident, so the charting is concurrent and sequential?
- Does the information show the use of the nursing process and critical thinking and problem-solving skills?
Nursing Documentation Principle 2: Education and Training
This principle is divided into two concerns. First, the nurse needs to have appropriate training on the technical requirements for documentation, including their facility’s documentation policies.
Second, any education and training should also focus on making sure nurses have the time needed for accurate documentation. Nurse training in this area should include the following:
- Skillful knowledge of the global documentation system
- Competency in using computers and other related hardware
- Proficiency in using the software systems used for documentation.
If a nurse isn’t comfortable or familiar with the skills needed to chart, then documentation doesn’t happen correctly if it’s even able to happen at all, and that affects other staff. Meanwhile, the patients aren’t getting the quality care they need.
Nursing Documentation Principle 3: Policies and Procedures
As stated above, nurses must be well-versed in any policies or procedures that the facility has regarding documentation. That might mean the restriction of the use of certain abbreviations, guiding procedures on what to do when you have to walk away from your computer screen, or policies on how charting is stored and accessed.
Nurses should also be familiar with what to do if charting software or hardware stops working for whatever reason, and the facility has to switch to downtime charting. If training is done well and downtime policies are appropriate, then any transition should be quick and relatively smooth, so patient care is minimally interrupted.
Nursing Documentation Principle 4: Protection Systems
All health care professionals in the United States should be very familiar with the Health Insurance Portability and Accountability Act (HIPAA). This fourth principle of nursing documentation is concerned with making sure all documentation and sensitive information is protected by those security systems.
For any charting system, whether paper or electronic, protection systems in place must meet government requirements in how they secure and protect patient information, health care professionals’ information, and the organization’s information.
Nursing Documentation Principle 5: Documentation Entries
While the first principle was concerned with the content of the documentation, the fifth principle guides the characteristics of the entry as a whole.
For every health care-related entry, including a charting entry of a doctor’s orders, the entry should have the following characteristics:
- Information that is accurate, valid, and complete
- A means of authentication, such as identifying the author and preventing any changes or insertions made after the fact
- Date and timestamps for when the entry was created that are tied directly to the entry’s author
- Standardized terminology, abbreviations, and symbols.
Nursing Documentation Principle 6: Standardized Terminologies
Lastly, the sixth principle is built upon the last. All documentation should use standardized terminologies, not slang or language specific to a location or unit.
Documentation is often used to collect data for research purposes, and using non-standardized terminologies can make organizing and gathering that data difficult.
Why High-Quality Documentation Is Important
High-quality patient care and good nursing practice involve high-quality documentation. Health care facilities should work together with nurses to continually improve documentation systems and policies.
Not only does that make the job easier, but improved communication means better patient care and a higher likelihood of catching mistakes or issues. Here are some other reasons why high-quality documentation is important in the nursing field:
- It improves communication among health care team members
- Documentation can help providers pick up on patterns that might indicate other health issues for patients
- As mentioned previously, good documentation is vital for research to understand and learn more about issues in the health care field
- Insurance companies use documentation to determine reimbursement
- Credentialing and auditing bodies use documentation to make sure facilities are practicing and upholding safe and quality patient care practices.
It can be tempting for some nurses to write off documentation as annoying busywork. But it’s so much more than that. As a nurse, you can better improve your nursing practice and patient care skills by working to continually improve your documentation. You’ll be helping out not only yourself but your health care team and the patients they care for.