Posted By by: Rey-Ryan P. Mapiles RN
What Is Documentation?
Documentation means “to give written information that is proof or support of something that has been done or observed.” Documentation is the written account of observations, the information the client, resident or family relates or states, the data you collect during care, and the care that you provide.
A medical record is a collection of information about the person you are caring for. It is a legal and confidential record with pertinent information related to the care provided.
We have heard it said over and over again, “ If you did not document it, it was not done”. We have heard this a thousand times. Lets look at what all this means………….
Simply put, a medical record is the record of all care that is provided. If it is not recorded, it did not happen. If it is recorded incorrectly, it happened incorrectly. This is why it is so important to be accurate when documenting.
Four most commonly used forms with particular importance are:
1. Nurse’s progress notes
2. Graphic sheet for vital signs
3. Care plans
4. Activities of daily living sheets
These are the forms where the most pertinent data is collected. There is little room for error on these documents. This is not to say that the rest of the chart is not equally as important, as the whole record is essential. These forms are particularly important because the content they contain sum up what was done ( or not done ) for the patient.
Legal Implications
Documentation provides crucial legal protection. Admissible in court, the patient’s medical record must be documented in an accurate, complete, systematic, logical, concise, and timely manner. Courts will view the documentation in the medical record as proof and verification to patient care. By showing that the individual under your care received quality, adequate care, a well documented record can, and will most likely protect you legally.
The medical record is a legal document. It is also regarded as highly confidential. In the event of a medical malpractice case, the medical record may be used to provide the court with evidence about a person’s condition and treatments. In a malpractice case, the jurors usually view the medical record as the best evidence of what really happened. For this reason, all documentation should be neatly written and legible. Illegible handwriting is handwriting that cannot be read or understood by others. This would account for sloppy writing, and often misspelled words and poor grammar. Illegible or poorly written documentation makes you look careless and distracted. Take the time to write neatly and clearly. Avoid words that are unnecessary or very long. When you abbreviate, make sure it is a standard abbreviation with no possibility of having more than one meaning.
DO NOT cover up anything in a chart with white out. Draw one line through it and indicate “error”, and be certain you initial it.
Nursebitz.com ALERT: if you didn’t chart it, you didn’t do it… has another meaning, if you did not do it, don’t have someone else chart you did what you did not. Also, do not document care provided by someone else. If there is a problem, you will be held liable.
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