When working in healthcare, the main goal is to take care of people and provide them with exceptional, evidence-based care. Healthcare takes a multidisciplinary approach, and they all share one thing in common: the need for thorough and appropriate documentation. 

It is rare to find a healthcare provider who will admit to enjoying documentation and charting. Most will agree that the thought of taking time away from caring for patients in order to type and click for much of your day can be frustrating. Documentation is one of the most important parts of the job, and it is necessary in order to protect the patient, the provider, and the institution. 

It is crucial that documentation accurately describes the patient presentation and any interviews, examinations, and procedures that occur. Documentation serves many purposes. It allows you to organize your thoughts, provides a trail to identifying problem areas and warning signs, allows for providers to plan and evaluate care, is a means of communication between the team members, provides evidence of the tasks you performed and what you observed during your shift, and provides legal protection (Mathioudakis et al., 2016). Proper documentation in a patient’s chart tells a chronological story about their care and health status. It allows for all team members to remain updated and connected on the plan of care for patients and how the patient is responding to that plan (Mathioudakis et al., 2016).

The use of proper documentation is crucial to support, evaluate, and chronologize events leading up to patient outcomes. In the case that a patients’ records are subpoenaed for court litigation, it is essential that the medical record gives details about their care, condition, and any changes that occurred during the course of their stay (Case Di Leonardi, 2009). It is always important to remember that when it comes to patient care, if it was not documented then it was not done (Case Di Leonardi, 2009)!

Case Di Leonardi, (2009) provides the following tips to keep in mind while completing daily charting: 

  1. High quality documentation is accessible, accurate and auditable to the reader. It should be clear, concise, and complete in its flow. It must also be completed in a timely manner and read in sequential order. 
  2. When handwriting in charts or on documents, it must be legible and readable. 
  3. It is key to document the patients’ clinical status and thorough assessment. 
  4. Utilize only the approved medical abbreviations.
  5. Know the institution’s chain of command, how to activate and utilize it, and make sure you document when and how you used it regarding patient care. 
  6. Focus on the patient. Make sure the documentation identifies the patient’s concerns, responses, and perspectives. 
  7. Documentation should include the education provided as well as psychological support. 
  8. Objective, clinical judgement should be evident in documentation. 
  9. Do not double chart. 
  10. Keep judgement out of documentation. Chart the facts and be precise. 

Understanding the importance of documentation and competence in documentation skills is key for every healthcare provider. Proper charting benefits the documenter, the rest of the healthcare team, and the patient. In any legal case involving an individual who was seen by a healthcare provider, the first documentation requested is for the patient chart. All providers should document in a way they would be comfortable with every piece of any patient chart being read aloud in court.  

References

Case Di Leonardi, B. (2009). Professional documentation: safe, effective, and legal. Retrieved from: https://lms.rn.com/getpdf.php/1939.pdf

Mathioudakis, A., Rousalova, I., Gagnat, A. A., Saad, N., & Hardavella, G. (2016). How to keep good clinical records. Breathe (Sheffield, England)12(4), 369–373. https://doi.org/10.1183/20734735.018016