Documentation

Each one of us can relate the type of documenter. I would asked you to question which one you relate to the most and how you can correct it to make sure that your documentation is a true picture of what is happening with your Resident.

1. THE EXTERMINATOR - These nurses use “white-out” or “scratch-out” to eliminate all traces of bad documentation. They are favorites among surveyors and lawyers who prosecute long-term care cases. NEVER, NEVER, EVER use “white-out” on a medical document. This should not be brought in your facility. (get rid of all “white-out”)
2. THE ABBREVIATOR - 72 yo www TBA admitted to SNF for STS s/p THR NWB A&O x3 Translation?? Another favorite with surveyors and prosecuting attorneys. Documentation should adhere to a set list of acceptable state abbreviations. Lawyers love “WNL”...they interpret it to be “We Never Looked”...
3. THE CRYPTOGRAPHER - These nurses practice under the concept that if it cannot be read, it cannot be held against them. Chart entries must be legible, not PRETTY! Many compliance and litigation issues are brought to court well past the actual event. Will you remember the event two years from now???
4. THE BETTER-LATE-THAN-NEVER - These nurses leave the facility and later remember that they did not chart at all or they forgot to chart something. So, they continue to make “late entries”. Make every effort to doc as events occur. A pattern of late entries or “missed” doc is a “red-flag”. For compliance and litigation purposes, the reliability of an entry made well after the fact would be questioned at length. According to the Board of Nursing, if you leave your scheduled shift without charting it is considered Abandonment of Patient Care and if reported to the Board it is reason for revoke of license.
5. THE REPLICATOR - “No changes in status continue with the current plan of care.” “No changes since previous assessment.” These nurses are the “copy-cats”! They just record in notes and flow sheets whatever the previous shift has reported. This practice leads to inaccurate documentation. Would you put your license on the line for an assessment documented by someone else????
6. THE PHANTOM -These nurses left the facility and realized they forgot to chart. So, they call the facility and ask the nurse on duty to leave a space for them to chart when they return to work on their next shift. BUT, their next shift is two days later and they FORGET to “fill in” the gaps in the documentation. Or, they try to squeeze all of the information into the space that is left. When they run out of room, they start writing smaller, smaller, smaller…then eventually start writing on the sides. A late entry is a better alternative, as long as it is not consistently abused.
7. THE EXPOSER - This nurse is a “confessor”. “Skin assessment was not completed upon admission, will pass on to the next shift to do.” “Busy shift, no time to do wound care.” When there has been an omission, the chart is not the place to complete a confessional.
8. THE OVER-LOOKER - These nurses never read the previous shifts documentation. If someone is not in the facility, how can an assessment be completed? This seems funny, but it happens all of the time.
9. THE PALM-OFF-ER - These nurses find something and chart at once regarding whose fault it was and who should have caught the problem – NEVER THEM!! “Previous nurse failed to change the dressing.” This makes EVERYONE look bad and with the lack of communication, makes the entire staff appear to be at fault.
10. THE INVENTOR - These nurses document in their own format, on their own forms, with their own color of pens or pencils, regardless of the facility’s policy. This practice tends to create conflicting information in the record, which would be questioned by reimbursement auditors, surveyors and lawyers.

Next month, I will attempt to tie up all the ends of Documentation to present a beautifully wrapped narration of how the patient felt during the given shift and what has been completed for that patient during the documentation period.