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					NURSING DOCUMENTATION
Objectives This independent study offering is designed for nurses and other health care professionals regarding nursing documentation and strategies to better articulate nursing care and practice. The multiple choice examination that follows is designed to test your achievement of the following educational objectives. After studying this offering, you will be able to: 1. Identify barriers to effective nursing documentation in acute care environments. 2. Differentiate between verbal and written communication of clinical nursing knowledge and practice. 3. Describe nurses' perceptions of the purpose and worth of their narrative notes in relation to the complexity and context in which nurses work. Most RecentHealth Care Articles
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4. Determine whether nurses document so as to influence nursing practice and theory development. Nursing documentation continues to draw criticism from professional, community, and regulatory organizations because of incomplete, substandard charting practices (Howse & Bailey, 1992; Parker & Gardner, 1992; Renfroe, O'Sullivan, & McGee, 1990; Tapp, 1990). Documentation is a fundamental nursing responsibility with professional, legal, and financial ramifications. Charting systems have, however, been consolidated to minimize the amount of irrelevant data and time spent in documentation.
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There is a concern that nurses may be less able or willing to document in ways that reflect the holistic nature of their practice and work. Further, questions arise as to whether the clinical record is the best medium for an accurate account for nursing's activities and holistic concerns. The purpose of this article is to describe a pilot study that explained nurses' perceptions of the functions and values of documentation and barriers to the process. The results have practice, legal, professional, and financial implications for nurses and health care delivery systems. Perspectives on Nursing Documentation Much has been written on the content and shortcomings of nursing documentation. Documentation has evolved into a nursing practice strategy to monitor and influence health care outcomes. Still, barriers to effective documentation have been noted in acute care environments. Three studies have specifically investigated these barriers.Renfroe and associates (1990) reported on the relationship between nurses' attitudes, subjective norms (or the influence of others), and behavioral intentions toward documentation. Gathering data on 108 nurses from three different southern hospitals, the researchers concluded that subjective norms rather than attitudes have the greatest effect on a nurses' intention to document optimally. They recommended communication of high ideals and expectations to the staff nurse from important others as ways to enhance optimal documentation (Renfroe et al., 1990). Tapp (1990) studied the degree to which nurses value documentation, including inhibitors and facilitators to this process. She interviewed 14 nurses from a western VA facility and found that redundant forms and imprecise language contributed to poor documentation. This research concluded that nurses lack a distinct professional identity and language as demonstrated by the inconsistent and devalued documented evidence of their care. Howse and Bailey (1992) interviewed four nurses from four different Canadian hospitals. Most importantly they identified cognitive and psychosocial factors, for example, poor self-confidence, writing skills, group normative structures regarding charting, and difficulty articulating the specifics of nursing practice as barriers to documentation.
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They argued that, while simplifying the process, streamlined methods of documentation may reduce the expression of clinical judgment and reasoning to automated rituals. Nurses have yet to define how best to discover and articulate their clinical focus, concerns, and actions. Their actions are typically described as compassionate, committed, and caring, yet these attributes are often difficult to recognize in the nursing documentation. Problems associated with written communication may be a

consequence of the lack of correlation between nursing practice and expectations for documentation. O'Brien and Pearson (1993) emphasized the importance of nurses' oral literacy in communicating the essence of nursing practice. They found that verbal exchange was used to explain and enhance holistic practice or the "how to" nurse. Verbal accounts of patient care situations were far richer than the recorded data. O'Brien and Pearson (1993) went as far as to say that much of what nurses do can only be transmitted orally. Rules and policies that govern documentation guard against exposing the daily risk and uncertainty of nursing. Yet this protective barrier may inhibit the discovery of knowledge embedded in clinical nursing.There is a growing body of literature that differentiates between nurses' verbal and written communication. Various factors have contributed to nurses' pervasive oral culture. The hospital unit is designed to achieve close working relationships where nurses can frequently discuss and reflect upon clinical choices both internally and with other disciplines. They successfully interact with patients, callers, visitors, and colleagues verbally. (In analyzing unwritten nursing knowledge, O'Brien and Pearson [1993] discuss the integral roles experience and reflection play in updating and validating clinical practice. However, the experiential knowledge of caring has been largely ignored or viewed as inconsequential by today's health care system.) These authors contend that the verbal exchange should be recognized as a legitimate approach to communicating nursing knowledge because it is impossible to completely capture the art of nursing in writing. Nevertheless, nurse experts generally agree that attempts should be made to clarify and track the essential aspects of nursing practice in the clinical record.
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Do's and Don'ts of Nursing Documentation Nurses are well aware of the standard, which states that if a certain matter affecting patient care is required to be charted and it is not, the overwhelming presumption is that it may not have been done. Good documentation will help you defend yourself in a malpractice lawsuit, it can also keep you out of court in the first place. The following excerpts are courtesy of NSO Risk Advisor-January, 1977. Do's
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Check that you have the correct chart before you begin writing. Make sure your documentation reflects the nursing process and your professional capabilities.

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Write legibly. Chart the time you gave a medication, the administration route, and the patient's response.

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Chart precautions or preventive measures used, such as bed rails. Record each phone call to a physician, including the exact time, message, and response.

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Chart patient care at the time you provide it. If you remember an important point after you've completed your documentation, chart the information with a notation that it's a "late entry." Include the date and time of the late entry.

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Document often enough to tell the whole story.

Dont's
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Don't chart a symptom, such as "c/o pain," without also charting what you did about it.

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Don't alter a patient's record - this is a criminal offense. Don't use shorthand or abbreviations that aren't widely accepted. Don't write imprecise descriptions, such as "bed soaked" or "a large amount." Don't chart what someone else said, heard, felt, or smelled unless the information is critical. In that case, use quotations and attribute the remarks appropriately.
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Don't chart care ahead of time - something may happen and you may be unable to actually give the care you've charted. Charting care that you haven't done is considered fraud.

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posted:6/6/2009
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