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Abstract
About
Documentation
Aspects
of Documentation
Analysis
Conclusion
References
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I
kept six honest servants,
They taught me all I knew,
Their names were WHAT and
WHEN and WHERE
And HOW and WHY and WHO.
--Rudyard Kipling
Abstract
The various purposes of clinical documentation are all best served by complete
documentation. A better understanding of the different aspects of
documentation can motivate nurses to become better documentors. However,
a technique to analyze one’s own documentation can channel that motivation
into empowerment. Using Rudyard Kipling’s “six honest servants”, a simple
and easy to remember technique to analyze one’s documentation is discussed
and various aspects of documentation are examined. By employing the simple
Invocation technique, which involves invoking the “six honest servants”
-- What, Why, When, Where, Who, and How -- nurses can enhance their documentation
skills and create complete, objective, and specific documentary records
about patient care.
About
Documentation
The need for clear and accurate documentation needs no emphasis. We as
nurses live with documentation in our jobs all the time, either directly
in documenting our own work or in generating information to document before
our shift is over. We know that there are different types of documentation
which different facilities use, and we individually are familiar with various
types. We learned about documentation in the class room, we learned it
in our clinical rotations when we were students, and now we practice it
in our jobs. We read about it, we hear about it, we wonder about
it, we think about it, and at times we get scared about it. Don’t
we?
With the ongoing emphasis on resource management, cost control, efficiency
in patient care, quality improvement, and accountability, we are required
to provide quality patient care and do effective documentation at the same
time. And, we are expected to fulfill those two major and sometimes
conflicting responsibilities with reduced staffing. When we cannot
fulfill both the responsibilities, we try to satisfy ourselves by fulfilling
the one with the higher priority.
Then which gets the top
priority? Good patient care, isn’t it? We don’t need elaboration about
it. However, can we be O.K. with it? We all know the answer. We know that
good patient care is a good defense against malpractice (Nurse’s Legal
Handbook, 1987). On the other hand, we have also read and heard
that clear and accurate documentation stands out as a defense in a court
of law in case of a malpractice suit. What we chart and how we chart
it speak for us and about us in front of the jury by displaying our competence,
our professionalism, our respect for the patients and their families, our
relationship with our colleagues on the team, and our degree of compliance
with the policies and procedures at the facility where we work. So
we cannot understate the significance of good documentation. So,
we could say that good patient care and good documentation are two sides
of a coin!
There is nobody out there to tell us how good or bad our charting is at
the end of our day’s work. However, we strive to be good at documentation.
In our desire to learn more about documentation and master its intricacies,
we read about it in the books and journals, and we attend seminars and
inservices on documentation. In the process, we learn a lot,
we adapt some into our practice, and we forget some. The process
continues. We agree that unless we address all aspects of documentation,
it would be difficult for us when called upon later to explain what we
did, why we did it, and how we did it without trying to dig into a memory
which could have faded by that time. But how can we distinguish between
adequate and inadequate documentation? How can we be sure that we addressed
all aspects of our interventions in our documentation if any given situation?
To be able to distinguish between adequate and inadequate documentation,
we need to know about different aspects of documentation. To ensure
that we have included all aspects of our interventions in our documentation,
we need a technique which is consistent, simple, and never forgotten! To
address this need, I utilize the services of “the six honest servants”
of Rudyard Kipling, author of The Jungle Book and Gunga Din, and a Nobel
Laureate in literature, to help us with the different aspects of documentation,
and provide us with a technique to assist us in complete documentation.
Those “servants” are: What, Why, When, Where, Who, and How.
Aspects
of documentation
What is documentation ?
According to The New International Webster’s Dictionary, a document is
a written or printed matter conveying authoritative information, records,
or evidence. The Nurse’s Legal Handbook (1987) defines documentation as
preparing and assembling records to authenticate the care we gave our patient,
as well as the reasons for giving that care. Thus, documentation
is the creation of an authentic record of patient care.
Why is documentation
necessary?
We remember some or all of the following purposes of documentation (Nurse’s
Legal Handbook, 1987; Eggland, 1988): to furnish authoritative information
on patient care, to help verify quality of care, to assist in the
coordination of care, to ensure continuity of care, to seek reimbursements,
to comply with regulations of the government and accrediting organizations,
to provide evidence in the court of law, and to generate data for research.
A clear, unambiguous, accurate, and complete record of patient care is
authentic. Quality of care simply means that what is done for the patient
is necessary, and that what is necessary is done. Coordination of
care is displayed when the different parts of the care -- care on
different days, care by different caregivers, and care from various departments
-- are harmonized into the whole patient care. Since coordination
is not subordination, we need to remember that the different parts of the
care are equally necessary.
Continuity of care is effectively demonstrated when care is documented
chronologically (Nurses Legal Handbook, 1987) by times, rather than narrating
it in blocks of time. The necessity of documentation in order to seek reimbursements
needs no elaboration, and it could be identified as the “bottom-line purpose”
of all documentation. Through adequate documentation it is possible for
us and for our employers to verify and to prove compliance with various
regulations and standards of care set forth by JCAHO, government, and professional
nursing organizations. Of course, what we document gets first verified,
analyzed, and tagged by our employers, their attorneys, and patient’s attorneys
before they talk to us, interrogate us, take depositions from us, and summon
us before the jury should a malpractice suit arise. Also, as professionals,
we know the importance of research-based practice, and we also understand
that sound data are a prerequisite for sound research outcomes. It
is no secret that only adequate documentation can generate sound reliable
data. Thus, the purposes of documentation reflect the fundamental
values of authenticity, quality, accountability, responsibility, professionalism,
and survival.
When is documentation
done or necessary?
We as nurses are required to document all patient care interventions from
the moment we enter a professional relationship with a patient and his
or her family. Our documentation ends with our termination of such relationship.
In between this initiation and termination of a professional relationship
with a patient, how often we are required to document is governed by our
work-place policies and procedures, our professionalism in implementing
the nursing process, and the condition of the patient. One
has to be familiar and comply with the standard frequencies of documentation
of initial assessments and routine reassessments, as well as in the complex
situations stipulated in those policies and procedures. Remember
that a institution’s policy is not the law (Nurse’s Legal Handbook, 1987);
however, institutional policies are supported in the court of law.
Additionally, those policies are developed taking into consideration the
regulations and standards of care by the JCAHO, government, and the professional
nursing organizations.
Where is the documentation
done?
Invariably each facility has its own forms and flow sheets developed for
the purpose of documentation by their staff. The total number of
forms and flow sheets available at a facility is not a constant number.
It could be 5, 10, 50, 100, or more. But, we know how many forms
and flow sheets, which I would say is less than ten, we use routinely on
our particular units. These forms and flow sheets are designed to suit
the type of documentation - SOAPIE (subjective, objective, assessment,
plan, implementation, and evaluation), PIE (problem, intervention, and
evaluation), or DAR (data, action, and response), facility
decided to have.
Who does the documentation?
The answer is obvious, is it not? We do, and they do, the documentation.
We are the nursing staff, including nurses’ aides. They are the non-nursing
staff: physicians, respiratory therapists, physical therapists, radiology
technicians, lab technicians, unit secretaries, and monitor technicians.
Remember, we and they, meaning all of us, coordinate care; and hence our
documentation reflects coordination as opposed to subordination.
All of us have to think and to believe that each piece of documentation
by any of us has equal status. Hence, one should not fail to document
any patient care intervention thinking that one’s particular intervention
may not be important compared to some other intervention by some other
care provider.
Who can document what is stipulated, required by a facility’s policies
and procedures? For example, at a certain facility the policy may state
that RNs can document all forms, perform all assessments, and develop plans
of care; LPNs may document all forms and may perform initial assessments
only if their competency has been demonstrated and documented; Nurses’
aides can document intake and output, vital signs, activities of daily
living, and specific tasks assigned to them but not assessments; Unit secretaries/Monitor
techs can document on kardex, medication administration records, and other
forms such as lab slips, radiology or dietary department slips to note
orders; and other department personnel may chart in the patient care notes
the specific tasks done by them. For example, a radiology technician may
document in the nurse’s notes as “patient taken to x-ray department
by wheel chair”.
Additionally, patients can self document in areas of chronic pain, blood
glucose monitoring, activity during holter monitoring, and blood pressure
monitoring (“Charting Tips.”, 1997). How and what kind of patient
care activities can be allowed to self-document is dependent upon a facility’s
policy and procedure. If you have one at your facility, use it; if
you don’t have one but want to have one, you may help develop it at your
facility.
How is documentation done?
We are individually unique in our style of documentation. However, we are
aware of the fact that while our various styles may differ, the principles
of sound documentation remain the same. Let us review those principles:
objectively, accurately/correctly, briefly, completely, timely, legibly,
specifically, flexibly, and sans pitfalls.
There is no place for subjective feelings, conclusions, opinions, impressions,
and suppositions in our documentation. Every piece of documentation we
create must be objective (Calfee. 1995; “Charting Tips”, 1997) - seen,
heard, smelt, counted, measured, performed. Documenting the subjective
expressions by the patients and their families verbatim in quotations is
objective documentation. By recording only facts, by using correct
abbreviations approved at our facilities, and by correcting our errors(“Charting
Tips”, 1997; Cirone, 1998) with the approved single line strike out and
designating it as an error as opposed to masking it, erasing it, or overwriting
on it we bring accuracy and correctness to our documentation. That means
we enhance its authenticity and in the process we enhance our credibility
as professionals. By giving only facts and by avoiding explanation
of any errors or omissions we can be brief in our documentation. However,
how long is brief is a subjective opinion. What would we say to the
person who answered the question, “how long should be one’s legs”? by saying
“from waist to the ground”. So, our documentation has to be long enough
to narrate the facts, and short enough to avoid unnecessary explanation
of errors, omissions, opinions, and judgments.
To keep our actions and patient outcomes in perspective, and to enable
better understanding of the patient progress, chronological charting is
preferred to block charting. Additionally, compliance with the minimum
requirements of time frequencies of our entries as stipulated in our work-place
policies and procedures is for our own good. If we don’t document legibly
today, how can we read the same in the future when we could be called for
a deposition? Documentation is communication between us and them
and sometimes ourselves.
Illegibility corrupts that
communication, and we will be at a disadvantage to defend ourselves. Neither
can our attorneys defend us if our communication is corrupted.
We have heard, read, and may at times have argued about what can be documented
and what cannot or should not be documented (Grane, 1996). We have
to document what is done to the patient. No exceptions there. Explain
positively why something is done. However, several experts have recommended
avoiding statements of defamation against a patient, opinions, alleged
negligence by coworkers, staffing problems, and words indicating error,
accident, unintentionally, or by mistake. If we have to report these
kinds of information or issues for whatever reason, maybe to vent our frustration
with staffing problems, maybe to fulfill a desire for extra-cautiousness
should something comes up later, or maybe to satisfy a need for risk assessment,
we can do so in “incident reports” which are not a part of the patient’s
medical record. Neither should we document a reference to such “incident
reports” in our documentation.
There is no single format that fits all situations we come across in our
jobs as care providers. Specific aspects of our interventions have to be
included in specific instances like patient transfer or discharge, discharge
against medical advice (AMA), assessment of suicide risk, patient teaching,
floating assignment, telephone triage, and patient transportation to a
different facility. We have to be familiar with our facility’s policies
and procedures with regard to documentation in such specific instances.
Additionally, one can find charting tips in various professional journals
covering these specific instances (Calfee, 1996; Eggland, 1997).
We have heard the axiom, “not documented means not done” (“Court Case:”,
1996). How about incomplete documentation (Eggland, 1995)? Incomplete
documentation can negate the purpose of documentation. Quality of care
cannot be evaluated, reimbursements may be rejected, the document cannot
stand as sound evidence in the court of law, authenticity will be
compromised, data generation will be inadequate, continuity of care may
be broken, and coordination of care may not be ensured. Hence, documenting
completely with specificities (for example, ate 50% lunch vs. ate lunch
well; called lab results to MD vs. called CBC, chem 7 results of 1600 to
MD) serves the purpose of documentation. By utilizing the same “six
honest servants” we can easily self-evaluate our documentation and enhance
our abilities to document completely and effectively every time.
Analysis
of documentation entries
We have reviewed the various aspects of documentation including its purposes
and the basic principles of documentation. Now, we can create “good” documents
about our patient care consistently, provided we have a technique
to evaluate our own documentation. We need that technique because
there is nobody else out there who will be continually giving us feedback,
nor do we have time to respond to such continual feedbacks at the cost
of equally important patient care. That technique we desire should
be simple and easy to remember. That technique is the Invocation
of six honest servants, and may be called Invocation technique. The
technique is simple, for it only involves Invocation of the six questions
– What, Why, Where, When, Who, and How - and finding the answers to those
six questions in the entry we are making. If all the six questions
are answered, we have a complete documentation entry!
Let us analyze a couple of charting entries using the Invocation
technique, and find out if it will work to help us ensure that our documentation
entries are complete, specific, and objective. Let us analyze and
compare the following two entries about the same intervention.
Entry No. 1
6/6/00
0900 IV heplock started in left hand...........RNavuluri, RN
Entry No. 2
6/6/00
0900 IV heplock started in left hand using 20 G cathlon, and
start kit per telemetry protocol....................RNavuluri, RN
When we invoke the six
honest servants, entry no. 1 will provide answers to when, what, where,
and who, but not to the remaining two questions, why and how.
When
..... 6/6/00 0900
What .....
IV heplock started
Where .....
in left hand
Who .....
RNavuluri, RN
Entry No.2 will provide
answers to the six questions as follows:
When
..... 6/6/00 0900
What .....
IV heplock started
Where .....
in left hand
Who .....
RNavuluri, RN
Why .....
per telemetry protocol
How .....
using 20 G cathlon, and start kit
Thus, we can say
that entry No. 2 is complete, specific, and objective. In general,
we invariably include the answers to questions: when, what, and who when
we document what we did. But, we miss on the other three: where,
why, and how. To illustrate this, consider the following entries:
Entry No. 3
6/6/00
0800 foley catheter inserted .........RNavuluri, RN
Entry No. 4
6/6/00
0630 ate 70% breakfast ..............RNavuluri, RN
The above entries no. 3 and 4 have the answers to when, what, and who.
Now consider the following entries no. 5 and 6 to replace the above two
entries no. 3 and 4 respectively.
Entry No. 5
6/7/00
0800 16 Fr foley catheter inserted urethrally by using sterile
technique per MD order successfully. The patient tolerated the procedure
without acute distress. Clear yellow urine return noted. ........RNavuluri,
RN
Entry No. 6
6/7/00 0630
Pt. sitting in chair. Pt. scheduled for EEG, Early
2g sodium diet breakfast served. Ate 70% by self feed.
Swallowing without difficulty......RNavuluri,RN
In these two entries no. 5 and 6, we can find the answers to all the six
questions. In entry no. 5, the answers are:
When
......... 6/7/00 0800
What
......... 16 Fr foley catheter inserted
Where ........
urethrally
How
......... by using sterile technique successfully
Why
......... per MD order
Who
......... ........RNavuluri, RN
The remaining information
in the entry “The patient tolerated the procedure without acute distress.
Clear yellow urine return noted” is necessary to indicate patient response,
and the outcome of the intervention.
In entry no. 6 the answers to all the six questions are:
When
........ 7/30/99 0630
Where ........
Pt. sitting in the chair
What ...........
Early 2g sodium diet breakfast served. Ate 70%
Why
.......... Pt. scheduled for EEG
How ..........
by self feed. Swallowing without difficulty
Who ................RNavuluri,
RN
Now, a question is whether the answers to all the six questions must be
explicit and clearly expressed in writing, or can some of them be implicit?
The answer is, yes, they can be implicit by common sense, or by professional
sense. For example, in entry no. 5, the answer to “where” can be implicit
without being spelled out. It is professional knowledge that foley catheter
is inserted into the urethra. However, it would be necessary to spell
it out, if it were to be a supra pubic catheter. Similarly, if breakfast
was served at a regular time unlike in the situation covered by entry no.
6, the answer to the question “why” would be implicit, by common sense.
However, to explicitly include answers to all the questions would not hinder
our documentation.
Another question is, what if we are using flow sheets to document part
of our care? We can use the flow sheets to effectively include answers
to all the six questions. For example, a flow sheet to document diet may
have provision to document when, what diet, how eaten (self vs. assist),
and who (nurse initials). It may not have a place to document “where”.
However, there could be another flow sheet to document the patient position/activity
at different times. If the patient activity at that particular time
of eating breakfast is charted in the flow sheet, the answer to “where”
is provided. Thus, by becoming familiar with flow sheets, and by
studying and practicing how to effectively link information between flow
sheets we can serve our purpose of ensuring complete documentation (Navuluri,
2000).
Conclusion
The Invocation technique of providing answers to the six questions of what,
who, when, where, why, and how can be an invaluable tool for use in all
situations of documentation of nursing care. The technique helps
us to ensure completeness in our documentation of patient care. Without
completeness in the documentation, the purposes of documentation cannot
be effectively served. A suggestion is that the Invocation technique
be used to stimulate our thinking while charting, to develop an independent
style of charting, and to link the information in various flow sheets and
narrative forms efficiently. As we learn to employ this technique
more and more to guide us towards completeness in our documentation, we
will also be able to increasingly appreciate the differences in common
sense, professional knowledge and compliance need. We cannot bring
completeness into an incomplete document by invoking common sense, or professional
sense on all occasions of omissions.
References
Calfee, B. E. (1995). Charting tips: Avoiding the charge of defamation,
Nursing95, Mar. 71.
Calfee, B. E. (1998). Charting tips: Avoiding generalizations, Nursing98,
Mar. 17.
Cirone, N. R. (1998). Charting tips: Correcting charting errors. Nursing98,
Apr. 15.
Grane, N. (1996). Charting tips: Comments that should stay “off the record”.
Nursing96, Jan. 17.
Eggland, E. T. (1988). Charting: How and why to document your care daily-and
fully. Nursing88, Nov. 76-84.
Eggland, E. T. (1995). Charting tips: Avoiding incomplete charting. Nursing95,
Oct. p73.
Navuluri, R.B. (2000). Charting tips: The six honest servants of good documentation.
Nursing2000, June, p22.
Court case: Not documented, not done (1996). Nursing96, October, p70.
Charting tips: How to document objectively (1997). Nursing97, July, p17.
Charting tips: Four things not to chart (1997). Nursing97, August, p25.
Charting tips: Teaching your patient self-documentation skills (1997).
Nursing97, October, p73.
Nurse’s Legal Handbook (1987). Springhouse Corporation, Springhouse, PA.
|
Books
on this topic from Amazon.com (click on book to order or examine):
Surefire
Documentation: How, What, and
When
Nurses Need to Document
Nursing
Documentation : Legal Focus Across Practice Settings
by
Sue E. Meiner
Handbook Of Home Health Standards
& Documentation: Guidelines For
Reimbursement
by Tina M. Marrelli
Nursing Documentation: A
Nursing Process
Approach
by Patricia W. Iyer, Nancy
Hand Camp
Rudyard Kipling Complete
Verse : Definitive Edition
by Rudyard Kipling
|
