Your Documentation Is Not Going to Save You

Is documentation the #1 thing that keeps patients safe and you from being involved in a malpractice suit?

No. Nope.

Probably not even in the top three.

The number one thing that keeps patients safe—and helps prevent the kind of harm that leads to litigation—is you: the well-trained, critical-thinking, patient-advocating nurse.

If you’ve read my article on the timing of documentation, you know I’m all about making documentation work for you.

Bend that ish to your will!

But there are a few more things we need to talk about, because documentation continues to be one of the biggest sources of anxiety I hear from nurses.

It’s tempting to use documentation as an easy scapegoat when we’re afraid of patient harm and lawsuits:

It must be the documentation!

Unfortunately, that’s not accurate. And I think it has become one of our favorite distractions.

That doesn’t mean documentation isn't important.

It is.

And it doesn't mean nurses can't benefit from sensible education about how to document well.

A lot of us can.

The problem is that so much of what nurses are taught about documentation is based in fear instead of helping us use the medical record as a tool for good nursing care.

And no wonder we're confused.

We simultaneously hear:

“Chart by exception.”

and

“Your documentation is all you’ll have when a lawsuit happens.”

We hear:

“Tell the patient’s story.”

but also:

“NO DOUBLE CHARTING!”

We hear:

“If it can go in a flowsheet, don’t write a note.”

So we spend our days searching for the perfect flowsheet row, somehow convinced that writing a narrative note is wrong.

Meanwhile, we slowly forget something important:

You actually do know how to chart.

You do. I swear.