Very often, the nursing progress note documentation is like cotton candy. I mean, you think it looks really good but when you get down to it, it’s just a sticky mess! Or, just a bunch of fluff with no substance.
In my humble opinion, electronic medical records systems often compound this issue. Actually, there are some pretty interesting articles and studies on the hazards of electronic charting.
One is the “copy-and-paste” syndrome. Say you have a bunch of monthly summaries to do. It is kind of tempting to just cut and paste last month’s. Unfortunately, this leads to missing out on the subtle changes that occur in our long-stay residents, which leads to misalignment between the nursing assistant ADL charting and the MDS.
Hey, this doesn’t just happen in long-term care. Look at the returning resident from an ER or hospital stay. The ER doctor incorrectly documents that the resident’s problem is related to a fall, and every other doctor the resident sees cuts and pastes that in his or her documentation and before you know it, you are being investigated for a fall that never occurred.
Or, you have the insanely long electronic daily skilled nursing note that has nothing to do with why your skilled short-stay resident is in the facility. So we have to dig through bowel sounds, and other non-related stuff to try and find documentation on pain or ADL function, which sadly may be missing. See, a hot sticky mess!
According to a review of electronic medical record pitfalls in Medscape, important findings can get buried in template charting. It is important for nurses to understand “why” they are charting on that particular resident and ensure the progress note portion is detailed enough to give substance to the “why” despite the template. It is also a good idea to have someone else review/audit these progress notes from time to time to see if the important information is captured, or if the note is just pink fluff.
Another problem according to Medscape is the dropdown menu in that inadvertently, a wrong item may be selected. I’ve seen this way too many times in my career since the advent of EMRs to count. So again, having the random audit to see if the note makes sense is important. But ladies and gentlemen, read your notes, please! Don’t leave this sticky mess for someone else to clean up!
Why do we document in the first place? We want to know what happened, what did we do about it, and what the result was. Something that if anyone else read it, it would make sense and that person would know what direction to go in.
So next time you go to document in whatever system you have, don’t just think of it as one more ridiculous task you have to complete. Simplify it to the basics, write “NA” if the EMR question is unrelated to you resident or leave it blank.
Just make sure your documentation has important, relatable information. That way you don’t have to worry about leaving a sticky mess!
Just keeping it real,
The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, an APEX Award of Excellence winner for Blog Writing. Vance is a real life long-term care nurse. 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. The opinions supplied here are her own and do not necessarily reflect those of her employer or her professional affiliates.