- If you are a nurse or health care professional, the phrase, “if it wasn’t documented, it wasn’t done”, is something you have likely heard, said, and/or thought during one of your shifts. For those that aren’t familiar with this phrase, it means that if there isn’t a record of the care you delivered in the patient’s chart, (by way of your documentation), the activity was not done. While this makes sense at face value, when placed in the context of patient care delivery, this statement has more extensive implications on documentation since health care organizations have transitioned from paper based records to electronic health records.
When on paper based records, nurses documented on the patient’s flowsheet, progress note, and care plans. The paper based records offered more freedom to potentially ‘go outside of the lines’. The boundaries were flexible but the paper record also left opportunities for unintended omissions. As the nation moved to electronic health records (EHRs) over the last several decades, we have fewer flexible boundaries. Additionally, nurses have more documentation options. Often, there are too many documentation options for the newer nurse who is concerned about a complete patient record, or the nurse who is terrified to be the one who didn’t chart his or her work. Thus, instead of unintended omissions, we now run the risk of having too many documented data elements that make it difficult to differentiate the essential from non-essential information.
For example, a patient admitted for cellulitis (e.g., skin infection) of the foot who on assessment has lung sounds that are clear bilaterally, does not require a comprehensive lung assessment documented of each lobe on the right and left lung. Another example might be a patient with a broken wrist and no prior medical history. The patient’s pain level, skin integrity, and mobility would be essential information needs. A complete neurological exam would not be essential in this case. However, today as a nurse looks at a blank electronic flowsheet, differentiating the clinical needs is not as obvious when considering the thought of ‘if it isn’t documented, it isn’t done’.
So, how do we support for the nurse and other health care professionals to differentiate clinical information needs without placing this on the individual person?
At a minimum, nurses must document the internal and external regulatory requirements. These regulatory requirements are evaluated on a regular basis through chart audits and continual education. However, the regulatory requirements are not always aligned with the care needs of the patient. For example, with meaningful use, documentation of smoking status for anyone over the age of 13 was mandatory. However, for a 14-year-old nonsmoker with heart arrhythmias, the smoking status is not relevant for the nurse working to ensure the patient has stable heart rhythms either through medication management, device management, or procedural intervention.
While we cannot eliminate the documentation of regulatory requirements, we can begin to think about how to help guide information standards for patient care based on the patient’s diagnosis and/or the unit based standards of care. (In my book, Electronic Health Records for Quality Nursing and Health Care, I refer to this section as documentation standards in Chapter 7).
The benefits of such efforts hold the potential for:
- Consistency of documentation across nurses of all experience levels based on patient care needs.
- Increased focus on documentation of essential information needed for decision making and delivery of patient care.
- A passive approach toward nursing decision support.
- Reduction in unnecessary or erroneous copy and paste charting.
To drive such efforts toward change, we will need the support of all stakeholder groups. These stakeholders include subject matter experts (SMEs), leadership (nursing and executive), innovators, vendors, and other influential external organizations. The subject matter experts (SMEs) are the clinical experts who are the nurses and other health care professionals in the front line. The SMEs know the information needed for care and know the evidence based guidelines. Leadership is essential to help foster the organizational support, goals, and execution of new initiatives. Beyond the SMEs and leadership team, we also need the innovators. The innovators are those who can view the current environment, listen to the challenges and opportunities and provide ideas for change from a fresh perspective and see the future. Additionally, the vendors and other influential external organizations must be involved to ensure the potential solutions are feasible and aligned with everyone involved in the process.
While I am confident that nurses and other health care professionals entered health care to care for people and not technology, we must be able to incorporate technology into our work days for the benefit of patient care. Just as we needed to learn how to use a stethoscope, trying to maximize the use of the EHR and other supportive information systems is just as essential. There are so many opportunities to help support our caregivers in ways that were not possible on paper. This is just one example of such an effort I hope we see in the future.