A New Year Commitment to Documentation
Hope you had a wonderful holiday and that your New Year is off to an exciting, productive start. On my list of things to do better in 2014, I'm adding getting paperwork completed more quickly.
Many nurses feel we provide excellent care but we are often bogged down with documentation. It's easy to overlook the importance of charting when you have many patients and their families vying for your attention.
From an infection prevention perspective, we need to know that certain key standards of care have been delivered - and the only way to show this is through documentation. Much of my time is devoted to monitoring adherence to these standards.
For example, when was that Foley inserted - and by whom? Is there a valid reason documented why the 60-year-old functional female still needs that catheter? Did your patient have his pre-op chlorhexidine shower? Did you deliver the antibiotics for his surgery on time?
Of course, we want these measures to be documented because it tells us the patient received appropriate care. But they can also tell us what may have been missed if there is an adverse outcome.
My time is also spent intervening when the standards are not being achieved. Working with the staff, we can determine: is it a product problem, a knowledge deficit or is the solution not appropriate to the problem? And of course, all of this is detailed in reports that I hope to disseminate more timely.
How is documentation handled at your job- are you entirely on electronic medical records - or a hybrid version? Has this helped with delivering care?