Just ask Petraeus
Real Nurse Jackie
Well, it wasn't easy to get there, but we have a new CIA director sworn in. With John Brennan taking over the spy agency, now's a good time to think back to what happened to his predecessor, General David Petraeus.
I've blogged a few times about the importance of being very careful about what you put in writing. As directors of nursing (and legal nurse consultants working for defense) can tell you, documentation is the bane of their existence.
I mean, don't people realize that eventually, someone is going to read what they document, either electronically or by pen?
Geez, someone even read what Petraeus wrote in emails. Nothing written is a secret. And for goodness sake, Petraeus is like the king of spies — the “M” of spies — and he got “read” and then busted.
The lesson here, kids: Don't put something in writing that's gonna bite you in the behind down the road. Hey, pretend you're a surveyor or, even worse, a plaintiff lawyer when you're documenting something. I mean, what the heck are you trying to put in these historic records?
OK here's the deal: Only ever document what happened, what you did about it, and what was the outcome. Why in the world do you write, “Resident had a good night”? First of all, who defines what “good” is? Don't document something that can't be measured or quantified, unless you are quoting the resident, “Resident stated she had a good night.” And only if the resident hadn't been having “good nights” and some intervention put into place changed the outcome.
Over documentation will kill you in litigation. Don't document unless you have to and again, only document something of relevance. Then, read it as if someone else were reading it. Does it really make sense?
That's because once it's written down, it's not a secret document just known to you and your workmates. It's now history, baby. Just ask Petraeus!
Oh, and if I could get my hands on the teacher who is out there instructing LPNs to start their documentation with “This writer…” What? Why? You're signing the note, right? Do we not know who you are? Writing “I” is OK. Really.
Just keeping it real,
The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, a 2012 APEX Award of Excellence winner for Blog Writing. Vance is a real life long-term care nurse who is also the director of clinical affairs for the American Medical Directors Association. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. She has not starred in her own national television series — yet.