Oh no, they didn't! More document nightmares
Jacqueline Vance, RN
As I've mentioned before, I believe nursing documentation is the bane of any nursing director's existence. Frankly, I think the look on my face when opening a medical record to the nurse's note section is exactly the same face I make when opening the stall to a public toilet. In other words, I never know what I'll find, and I'm prepared for something scary!
I miss the good old days when nurses actually documented something relevant to the resident's stay. Come on, people … think!
Why is the resident there, or has something just happened, or are you following-up on something that recently happened? Don't document for the sake of documenting. I mean, I have seen some nurses' notes that would make you quake in your Nurse Mates or Crocs.
You'd be like, “Wait, they wrote what?!” and “Oh no, they didn't!” (Or did they? I can't tell because this note makes no sense!)
OK, let's also take another look at our documentation polices, please. I think some of the problem is that we ask our nurses to document on some archaic policies we have because we don't understand Centers for Medicare & Medicaid Services mandates. Did you know that in the Medicare Benefit Policy Manual – Chapter 8, we are told that we only need to document on a skilled resident's stay once per 24-hour period? So unless something significant happens, why are we making everyone chart per shift (more than vitals or whatever)?
Worse, I think some electronic medical records are hurting us. EMRs might be proclaimed as a potential “game-changer” for the healthcare industry, but many of them just stink as far a nursing documentation goes. They might just have a pull down menu of options that might not be relevant to the resident's condition. I prefer systems that use data in a structured way that is combined with what is known as skip logic, which guides nursing documentation. For example, with skip logic, if you check a data box that a resident is having difficulty breathing, it takes you through logical questions that you answer so that your documentation, as well as assessment, is logical and meaningful. In other words, it makes sense! Otherwise, it isn't gonna' hold up when you're audited for that Med A stay.
Actually, the National Nurses United, in highlighting the potential dangers of “unproven medical technology,” in relation to the problem of nursing documentation, stated that FDA officials should test electronic medical records as rigorously as they might a new drug or an artificial hip implant. I don't know about that, but I do know that any EMR you choose has to allow for a good narrative if needed.
So just remember those 3 W's —
For changes in condition: What happened/is happening? What did you do about it? And What was the outcome?
For Med A stays: Why is the resident there? What do you need to document to support the stay? What are you doing to prepare them for their return back to the community?
And finally, pray your nurses can either type or have legible handwriting. That always helps, too! (After all, we're nurses, not doctors! LOL)
Jyst Keppng ot rela,
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. 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.