Yeah, I know, for someone who is all like “you don’t need more classes on documentation!” I’m really on a documentation streak right now. But if you are still with me on this 3 part journey (see my other articles here and here), then I feel like I owe it to you to talk about how to chart. Nothing special or magical. Which is why all the scary or mixed messages we receive around charting as birth nurses don’t add up for me. I know you know how to document. You are already super smart and know how to chart. It’s tempting to use documentation as an easy scapegoat when we have fears around patient harm and lawsuits (“It must be the documentation!”). Unfortunately, that’s not accurate and it’s become a favorite distraction. That doesn’t mean it’s not still a little confusing. And you know what? It makes sense that it’s confusing! Partly, that’s because of the mixed and fear-based messages. Part of it is because of the many function documentation plays besides patient safety. Let’s look at why the EHR (not you,) is the problem and how to reclaim documentation as the important nursing clinical activity it is.
So Why do Hospitals Talk About Documentation So Much?
There are many reasons why documentation is important and it’s only partly for patient safety. There’s also compliance with state and federal regulations and (perhaps most importantly) having sufficient documentation for billing and reimbursement, also known as “charge capture”. Epic is a very common system and it is definitely King of Charge Capture. Is it the greatest at “telling the patients story”? No. Hands down the old VA system Vista was amazing at both getting information in and back out for clinicians and allowing them to construct an effective patient story. But because it was built for the VA, a system that didn’t need to be concerned with billing, no other healthcare entity adopted it, even though it was available to any hospital for free. If you’ve been part of a switch to Epic, you know it is incredibly expensive. But Epic is a charge capturing machine, so it’s what we all mostly use. Are regulatory compliance and generating income for the hospital important? Yes! But I think it’s a lot more intellectually honest to say that, then to pretend it’s all in the name of patient safety and lawsuit avoidance.
The Nursing Process (she’s baaaaaack!!)
Your hospital will have guidance on some of the basics, like how often to chart an assessment of a fetal heart rate tracing during labor, when you started an IV, scanning meds into a MAR and how often to check temperature if a patient has ruptured membranes. After that, it’s just the nursing process. Super boring, but we learned this in nursing school. The nursing process is Assessment, Diagnosis, Plan, Intervention, Reassessment. You are probably doing this and don’t even realize it. For instance, you assessed and documented the fetal heart rate tracing. Because of minimal variability and variables you diagnose it as a Category 2. You plan to improve the oxygen status of the baby and intervene by doing a position change, IV fluid bolus. Fifteen minutes later you reassess that the fetal heart rate is moderate variability and no decelerations and diagnose it as a Category 1. Then you plan to support physiologic birth and “intervene” by staying at the bedside and utilizing the peanut ball. You reassess that the patient is verbalizing that they’re coping and her contractions remain in a regular pattern with increasing strength. What I might see in the chart is the heart rate tracing and contraction assessment, the IV fluid and position change, a pain assessment that states patient coping and a note stating you are supporting patient labor at bedside with peanut ball and position changes. This is going to look different nurse to nurse; it’s your nursing process so the charting is going to be a little unique to you and your patient that day (or night). The nursing process is so powerful, that the added benefit is if you are engaged in it, these aren’t the patients whose case I see as an expert witness.
“If it can go in a flowsheet, then don’t write a note” is like saying “tell me your patients story using only emoji’s” (notes are in!)
So for all the benefits of an EHR (portability, charge capture, etc) there are several significant drawbacks that we need to be mindful of. First, the EHR negatively impacts our clinical reasoning and interprofessional collaborative practices. With a paper-based chart, each clinician told the patient story in their own words, consolidating and interpreting a wide array of patient data. This was considered a vitally important skill that was required to provide patient-centered care, within an interprofessional team, that safeguards patient safety and clinicians' professional credibility. Research has revealed that EHR use obstructed clinicians' ability to build the patient's story by fragmenting data interconnections (entering stuff into individual flowsheet rows). Further, the EHR limited the number and size of free-text spaces available for narrative notes. This constraint inhibited clinicians' ability to read the why and how interpretations of clinical activities from other team members. This resulted in the loss of shared interprofessional understanding of the patient's story, and the increased time required to build the patient's story. So notes are back in. How to write a note? Well since I’m a nurse educator, I have to make up an acronym!! This applies to charting overall, and also specifically to notes.
Super-clear: both all the details—who, what, when, where AND why its important i.e. just show the nursing process.
Near-time: near to the time the care is given, usually within 30-60 minutes. It’s like, real-time charting’s cousin who works on an occasionally under-staffed unit..or night shift. There are some exceptions that really do need to be real-time. For instance, fetal monitoring. That q 30 minute cut and paste smells worse than when you leave your Danskos in the car. Especially if you're back-charting the whole shift.
Attentive: Chart like you give a heck about your patient! Tell me about the conversations you had, all the times you helped her into a new position (if it’s a note summarizing is fine i.e I used the Lavone circuit), the details of her birth preference. If they’re a patient that’s difficult to monitor, tell us! And then tell us all the things you tried to improve the tracing. Also, if you can’t find the tracing, but the pt reports kicks or you hear movement-document it! That shit is gold and it tells me you understand fetal physiology--double-score!!
Patient-centered: Patient engagement goes up and the incidence of birth-related trauma goes down when the patient is communicated with. And not just informed of the plan the provider has decided, but actually the one given the information, time and support to make the decisions themselves. What did they say, think, feel? What alternatives were discussed? Use names and language that if the patient read this, they would understand. We can really go overboard with the academic language, but it’s okay to be quite plain. In fact, one of the best things you can do for engagement is to read back notes and significant entries to the patient and support people to make sure you got it right. Sure, not in the middle of a contraction or if it’s going to mess up the whole vibe, In general I will read back documentation to a patient about what I’m communicating on their behalf to a provider and after a significant event to help them understand what happened.
So there you have it! Why documentation in an EHR is challenging (yes, you are validated!) and how you can cut through that to reclaim our nursing art of chart...ing. Not only can the act of charting in near-time, with the engagement of the patient decrease their birth-related trauma, it is also key to helping us in our clinical thinking. Let it be a key helper in your nursing process.