Nurses protect the welfare of patients by recording contemporary and confidential nursing documentation.
The documentation helps ensure high standards and continuity of care.
And demonstrates the duty of care that nurses provide to patients.
So why is documentation so time consuming, and sometimes is unnecessary to the delivery of care?
One study in the Journal of Research in Nursing by Liz Charalambous and Sarah Goldberg asked nurses their experience and attitudes towards the documentation that they are asked to complete.
Nurses know that skilled and experienced nursing care can be time consuming and difficult to deliver.
But nurses do work in multidisciplinary teams and the provision of accurate and meaningful documentation ensures the delivery of safe and effective quality care by the whole health care team.
No one denies the importance of accurate record keeping.
But nurses would say that at times the way they are asked to document care can be painful because of the design of the documentation and the sheer volume that is required to be completed.
A Royal College of Nursing survey found that the 86% of nurses believed that non-essential paperwork had increased over the previous two years.
And that paperwork prevented them from spending time with patients.
Current record keeping procedures are impinging on and failing to support nursing practice.
Electronic nursing documentation is held up as a panacea to these obvious problems.
But electronic nursing documentation may not lead to less time documenting care.
And there is no evidence that using electronic nursing documentation improves patient care.
Recording patient observations electronically would have a time saving benefit as well as the use of photography in day to day review of care sure as pressure area wound care.
But that is small beer to the rest of the volumes of documentation that the average nurse faces.
It is this documentation that practicing clinical nurses rarely have much input into the how the documentation is recorded.
Charalambous and Goldberg identified common themes about documentation that nurses use.
The themes were issues around time, amount of documentation, inaccuracies, surveillance and defensive practice.
There are gaps present in the information documented.
It was missing, inaccurate or inconsistent.
Where there were gaps in documentation, there was an assumption that the care had been carried out despite it not being recorded.
There were mishaps that were the consequence of inaccuracies and inconsistencies.
Documented care did not always correspond to the condition of the patient.
And finally, there were overlaps; which was a direct result of repetition and duplication in the paperwork.
It was repetitious and often of no discernible benefit.
The whole documentation process leads to the omission of important information, inaccuracy, duplication and safety concerns.
Some nurses described how information could not be accessed despite it being recorded numerous times.
Paperwork was filed away and left unused.
Gaps, mishaps and overlaps in documentation will lead to patients being harmed unnecessarily.
But there is a benefit that shields nurses when documenting – they can demonstrate that they have provided the care, if challenged.
The difficulty is getting the balance right between too much and not enough documentation.
The Goldilocks, or just right, position will not be a one size fits all solution imposed from above.
It is the nurse who provides the care that can identify what needs to be recorded and what doesn’t need to occur.
There may be many different reasons an organisation may require other information.
But it is a role that does have nursing implications and should not be undertaken by others who may require it.
Documentation design needs to begin and finish with the people who use it everyday.
After all, nurses are the professionals with the patient 24 hours a day and provide the most frequent and intimate care.
Nurse do have access to information about patient’s that no one else does.
They should record that and forget about the ‘administrivia’ that consumes their time.
Let the ‘administriviators’ collect their own data.
To learn more about documentation,