The Importance Of Clear And Accurate Documentation

Practice Nurse Debbie talks about the importance of clear and accurate documentation, and gives us advice on how to ensure this key part of nursing practice is done correctly.

Hello, my name is Debbie, and I'm a Practice Nurse in London. Today, I'm going to be talking about the importance of ensuring we as nurses have clear and accurate documentation.

Now you've seen it before, we've heard it before, and we've learned here, throughout our studies, the importance of making sure that our documentation is clear and accurate. Recently, there was a trial in America concerning a nurse who gave the wrong medication simply because there was miscommunication in documentation.

Why is it important that we have clear and accurate documentation?

Patient Safety

Well, number one, is patient safety; that the next person who is taking over care is able to understand what we have written or what we have typed. As a Practice Nurse, I've spent a lot of time typing. If you want to be a practice nurse, you are going to spend a lot of time typing and typing and typing, so get used to it.

Patients Can Now See Their Documents

And another reason is recently patients have been allowed to see their documentation, and it's important that what happened in the consultation and what has been said in the consultation reflects what you have typed or what you have written.

The Five W’s (And One H) For Documentation

I'm going to use the five W’s and one H to explain how I generally document:

Who?

So, who. I start with who was present in the room, who was present during the consultation. Was there a parent, was there a partner, was there a friend, was there another student, was there a Student Nurse, a Student Doctor, who was there?

At the end of the day, when all is said and done, years down the line, those who were there are going to be those who vouch for you in that appointment.

I also mentioned who did what. For example, when I have a procedure with a doctor, for example a coil insertion or coil removal, or implant insertion or removal, or if I'm just there to assist something, I will say who did what and that I assisted the procedure, and that the doctor did X, Y, and Z. So make sure you write who did what.

What?

Number two: what. What did the patient come in for, what did you do for them, what has been said, what has been explained, and what should be done.

Where?

Number three, where did it happen? If a patient explained something happened, where exactly did it happen? Did it happen at home, at the shopping center? A lot of times I get patients who have had a fall. Where did it happen?

Why?

Why? What is your clinical judgment, your clinical reason for doing what you are doing? For example, when I see patients that have that need a dressing and I put a specific type of dressing, I would say in order to absorb any excess fluids or in order to etc... I give the reasoning as to why I am doing what I am doing.

When?

When. When did the symptoms start? When did it take place? When did this happen? A lot of the times I get patients who maybe had a surgical procedure and I make note of when this procedure was.

This helps to know if the wound is truly healing according to the way it's supposed to heal. If the patient had this surgery two months ago and it's still ongoing, this will be a different treatment to someone who had this wound two days ago and the wound is still healing.

So write down when this procedure happened or when (roughly) something has taken place.

How?

And how. For example, if we have a procedure, I would make sure that I've written that it is was aseptically done; that we have done this procedure, making sure that everywhere was clean.

It seems insignificant, but all of these little documentations are important to note down for your own safety and covering your own back.

It's covering ourselves, as healthcare professionals, to make sure that our clear and accurate documentation is reflecting what is being said during each consultation.

Make A Note Of What Your Patient Reports During Consultation

One of the things I like to make sure that I write in my consultation is, “the patient said”, or “patient reports”, “patient mentions”. This shows that the patient has been able to express what they think is going wrong or what they have said concerning their condition and not just what I have advised or recommended.

All of these are very important and as much as it is for patient safety, it covers your back as well.

Keep A Record Of Where You’ve Been And What You Did

A lot of the times when we chaperone for doctors. If a doctor needs me to stand in the room for any reason, e.g. he wants to do an examination and needs me to be in the room, I have to document that I was there and I chaperoned as the doctor did X, Y, and Z because years down the line, God forbid if anything was to happen, my notes are there to verify what he has said.

So it's covering ourselves, as healthcare professionals, to make sure that our clear and accurate documentation is reflecting what is being said during each consultation.

I hope this helped.