Nursing Documentation Nursing CE Course

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The purpose of this module is to provide an overview of nursing documentation, outlining the professional standards, most common documentation errors, and legal risks of incomplete nursing documentation amidst evolving technology and reliance on electronic medical records. 

Upon completion of this module, learners will be able to: 

• describe the importance of nursing documentation and identify the essential components of documentation to meet professional nursing standards 

• describe how nursing documentation has shifted toward electronic medical records (EMRs) 

• identify the legalities of nursing documentation 

• recognize common documentation errors, contributing factors, and "do not use" medical abbreviations 

Background 

Thorough and accurate documentation is considered a professional standard of nursing practice, safeguarding patient care, reducing the potential for miscommunication and errors, and promoting quality outcomes. The American Nurses Association (ANA) views nurses as individually responsible and accountable for maintaining professional competence. Documentation is valuable for demonstrating that nurses have applied appropriate knowledge, skills, and clinical judgment according to professional nursing standards. Documentation must meet professional and employer standards, as well as pertinent legal criteria (ANA, 2010; Woods, 2019).  

Overview of Nursing Documentation 

The quality and coordination of patient care depend upon the extent and usefulness of communication among all members of the patient's healthcare team, with the medical record serving as the central vehicle of this interaction. In the modern era of healthcare, communication is primarily done through recording and reporting. Therefore, high-quality documentation is necessary and indispensable across all facets of nursing care. Nursing documentation is the process of preparing a complete record of handwritten or electronic evidence regarding a patient's care. It includes the nursing assessment (e.g., intake and output, vital signs, head-to-toe assessment), nursing care plan (highlighting the patient's healthcare needs and outcomes), interventions, education, and discharge planning. Accurate, timely, and detailed documentation shows the extent and quality of the nursing care provided, the outcomes of that care, and any treatment and education the patient still requires. Proper documentation establishes professional accountability and demonstrates nursing knowledge and clinical judgment skills. It also verifies that the patient received care according to the institution's policy, industry standards, and state regulations (ANA, 2010; McCarthy et al., 2018; Woods, 2019). 

Beyond fostering high-quality and continuous care, comprehensive and precise nursing documentation serves several other purposes. It is vital for quality assurance, as accrediting agencies and other regulatory bodies use documentation to evaluate patient care quality. Insurance companies and payors use documentation systems to verify the care received and render payment to the organization. Such documentation serves as a legal document that becomes a central part of proving whether standards of care were met if issues arise. It may also be used for research and education and to help organizations assess funding, professional education needs, and resource management (Craven et al., 2021; McCarthy et al., 2018; Woods, 2019).   

Professional Standards 

The ANA's Principles for Nursing Documentation indicate that high-quality nursing documentation must follow regulatory guidelines and mandates across all nursing roles and working settings. Last revised in 2010, this document remains the gold standard for the basis of nursing documentation, with six essential principles serving as primary guidelines, as outlined in Table 1. Nurses must also acquire a keen awareness and understanding of their state's nurse practice act to ensure documentation reflects specific state laws. Furthermore, nursing documentation includes the organization's choice of forms and technology, requiring nurses to adhere to policies and procedures established by their facility (ANA, 2010, 2021). 

Nurses must also be familiar with the ANA's Scope and Standards of Practice (2021), which outlines the required competencies of nursing documentation utilizing critical thinking and the nursing process. The standards state that nurses must document the following: 

• relevant data accurately and in a manner accessible to the interprofessional team 

• diagnoses, problems, and issues in a way that facilitates the determination of the expected outcomes and plan 

• expected outcomes as measurable goals 

• the plan of care using standardized language or recognized terminology 

• the implementation and any modifications, including changes or omissions, of the identified plan 

• the coordination of care 

• the results of the evaluation 

Furthermore, nurses must contribute to nursing practice by documenting in a manner that supports quality and performance improvement initiatives (ANA, 2021).  

Paper-Based Records vs. EMRs 

The evolution of healthcare information technology over the last several decades has steered the field of healthcare from paper-based medical records to nearly complete reliance on EMRs and technology for all aspects of patient care. Some institutions continue to utilize certain aspects of paper charting, with the EMR complementing the paper record. However, most healthcare organizations have transitioned to wide-ranging, all-encompassing EMR-based systems. The EMR and paper medical records typically contain the same documents, with the EMR primarily viewed as a digital version of a patient's paper chart, but they are profoundly different. EMRs have reshaped healthcare delivery. They offer many tools and features designed to enhance communication among healthcare providers, increase productivity, and improve the quality and utility of clinical documentation (Craven et al., 2021; McCarthy et al., 2018). 

The EMR allows information to be stored in a single place that is easily accessible by all healthcare team members. This accessibility facilitates timely intervention when acute changes occur in a patient's clinical status. The EMR simplifies communication exchange and allows providers to order medications, tests, or procedures remotely to expedite quality care and improve outcomes. The EMR also meets many of the criteria of Principle 1 of the ANA's six essentials. It enhances accessibility to the patient's chart for all team members and simultaneously from various locations. Additionally, the EMR facilitates audits of the medical record, allowing for a more straightforward evaluation and tracking of data. It eradicates the concern for legibility by removing the variable of handwriting; however, documentation must still be 'readable' with proper grammar and spelling. The EMR facilitates the timely, contemporaneous, and sequential aspects of charting, as most EMRs automatically time-stamp entries, allowing for an immediate, fast, and precise timeline of documentation entries. Furthermore, information is permanently retrievable, as the EMR saves information immediately, removing the possibility of lost paper records and charts. The EMR is also useful in managing patients with complex health conditions and comorbidities, enhancing follow-up visits and continuity of care. Many EMRs offer time-saving features, such as automated processes that boost clinical accuracy, and tools (i.e., sepsis scores) to improve patient safety and outcomes and decrease the overall cost of healthcare (ANA, 2010; Craven et al., 2021; Lee & Lee, 2021). 

Whether nursing documentation is paper-based or electronic, the requirements remain the same: clear and concise patient care information, reflecting responsible professional judgment, that is signed, time-stamped, and dated within an appropriate time frame. While many additional benefits extend beyond those highlighted within this module, EMRs also have several pitfalls and dangers regarding documentation (i.e., workarounds) that did not exist with traditional paper-based documentation. For example, while "auto-populate," "cut-and-paste," and "copy forward" features have been designed as time-reducing efficacies, they have also enhanced the margin for documentation errors and carelessness by replicating inaccurate information inadvertently. In addition, EMR documentation can be even more limited than paper-based records. For example, completing pre-populated assessment templates and checkboxes generally does not accurately depict a patient's clinical status. If all checkboxes are not filled, it may appear that blank items were not addressed or not observed by the nurse. Nurses have been surveyed regarding their perceptions of documentation processes during the transition from paper to electronic systems. The majority described concerns regarding redundancy, excessive time away from direct patient care, inadequate training in the functionality and use of the EMR system, and increased overtime required to complete documentation (ANA, 2021; Craven et al., 2021; Lee & Lee, 2021; O'Brien et al., 2015).  

Unfortunately, the current state of various EMR systems has been shown to increase the burden of documentation for many nurses, further limiting the ability to deliver personalized, evidence-based, and efficient patient care. While evidence-based practice (EBP) is a core competency in the nursing profession, few EMR systems are equipped to guide the delivery of EBP. Most nursing documentation within the electronic record is consistent with data entry, as many systems offer discrete fields in flowsheet rows and columns instead of free text. This type of nursing documentation omits valuable aspects of patient care, creating several gaps and inconsistencies in each patient's overall clinical picture. Furthermore, regulatory and accreditation requirements associated with the EMR also increase the documentation burden imposed on nurses and contribute to data redundancy. Documentation burden has been associated with nurse and provider burnout, highlighting the need for solutions to improve efficiency and experience with documentation. Despite the EMR system's present challenges, nurses must perform safe, high-quality patient care with supporting documentation (Capriotti, 2020; Gesner et al., 2019; O'Brien et al., 2015). 

Legalities of Nursing Documentation 

The medical record is often the most critical piece of evidence in a malpractice lawsuit. In a court of law, the patient's medical record serves as the legal evidence of the care provided to that patient to defend against allegations of malpractice, negligence, or failure to meet standards of care (Jacoby & Scruth, 2017). Legally, the term standard of care is defined as: 

The ethical or legal duty of a professional to exercise the level of care, diligence, and skill prescribed in the code of practice of his or her profession or as other professionals in the same discipline would in the same or similar circumstances. Failure to meet the standard of care is considered negligence, and the healthcare provider will be held liable for any damages caused by such negligence. (Edwards, 2017, p. 1)  

Professional negligence is any failure to provide the standard of care to a patient that results in an injury or damage to the patient. In the event of a lawsuit, an omission is a form of neglect, which is where the well-known phrase "if it was not documented, it was not done" applies. Some organizations have shifted from "if it was not documented, it was not done" in favor of charting by exception (CBE). CBE permits the nurse to document only those findings that fall outside the standard of care or norms defined by a specific institution. Healthcare organizations must develop written standards and norms for patient assessment or care activities. The nurse then documents any assessment findings or care activities outside the norm or standard. CBE requires less nursing time for documentation, and changes in patient status can be readily detected. The main disadvantage of CBE is the time needed to develop the norms and standards for the organization. There is also concern about the potential legal challenges implied by the precedent "if it was not documented, it was not done" (Craven et al., 2021; Jacoby & Scruth, 2017). 

A case commonly referenced in malpractice literature is Susan Meek v. Southern Baptist Hospital of Florida in 2006. In this case, the patient was admitted to the hospital for a hysterectomy (i.e., surgical removal of the uterus). Postoperatively, she developed abnormal bleeding and required uterine artery embolization to stop the bleeding. Due to the known risk of diminished blood flow and subsequent nerve injury to the lower extremities, the physician ordered frequent leg assessments. The patient suffered nerve damage after a blood clot was removed from the external iliac artery, and the patient claimed the leg assessments were not performed as ordered. Due to incomplete nursing documentation, it remains unknown whether the nurses performed the leg assessments. Therefore, based on the absence of documentation, the patient won the lawsuit and was awarded $1.5 million in damages (Edwards, 2017). 

One of the cardinal principles of legally defensible documentation is adherence to organizational policy and procedures, standards of care, guidelines, competencies, and other organizational documents that guide patient care. Improper documentation can leave an employer (and the nurse) liable and vulnerable to a malpractice lawsuit. If there is a deviation from any of these policies, the nurse must support the reason for the variation within their nursing documentation (Craven et al., 2021; Edwards, 2017). 

Documentation Errors 

Among the various types of nursing errors, documentation errors are some of the most frequently cited in the literature. Root cause analyses indicate that nursing documentation errors are commonly due to a lack of awareness, high workload demands, redundant information, and a lack of standards. Omissions in nursing documentation can also be due to a lack of training. These mistakes can be compounded by the design of certain charting forms, which can be complicated, time-consuming, difficult to navigate, and not user-friendly. Other causes include a lack of or inconsistent standards on nursing documentation, poorly defined institutional policies, and inadequate knowledge, awareness, and training. Staffing shortages and heavy workloads can result in insufficient charting time, as nurses devote most of their time to patient care responsibilities. Nurses' perceptions and resistance to documenting also contribute to documentation errors, as they may view documenting as an obligation rather than a professional responsibility. Furthermore, nurses describe heavy workloads as factors generating perceptions that documenting is a less critical task. As a result, the quality of the documentation is compromised, and errors are inevitable (ANA, 2021; Eltaybani et al., 2018; Gesner et al., 2019). Some of the most common types of nursing documentation errors include: 

• illegible handwriting (less of a factor with EMRs) 

• incomplete or missing documentation, such as a failure to record nursing activities 

• failure to date, time, and sign a medical entry (many EMRs do this automatically now) 

• lack of documentation justifying omitted medications or treatments 

• documenting subjective data 

• not questioning incomprehensible orders from medical providers (less of a factor with EMRs) 

• using the wrong abbreviations or those that are not approved 

• entering information into the wrong patient's chart 

• not recording drug-related information, including a drug reaction or any change in patient status 

• documenting prior to care given 

• delayed entries (Craven et al., 2021; Edwards, 2017; Eltaybani et al., 2018)  

Documenting Medical Errors 

In the Institute of Medicine (IOM) report To Err is Human: Building a Safer Health System, preventable adverse events in hospitals were a leading cause of death in the US. Per this report, approximately 44,000 to 98,000 people die annually due to medical errors. The IOM noted that reporting errors are fundamental to preventing future errors, which gave rise to mandatory reporting systems. These systems were created to foster healthcare environments where safety is the top priority. A wide range of mandatory reporting requirements applies to healthcare facilities at the federal, state, private sector, and accrediting organization levels (IOM, 2000). Among states, there is a wide variation in the types of individual events reported. According to the National Academy for State Health Policy (NASHP, 2015), 27 adverse event-reporting systems exist across 26 states and the District of Columbia. 

According to Standard 9: Communication of the ANA's Scope and Standards of Practice, professional competency and expectations for nurses is to disclose concerns related to potential or actual errors in patient care or within the practice environment to the appropriate level. This expectation includes any errors a nurse makes. Each organization should have a policy on reporting and documenting medical errors. Generally, medical error reporting occurs through a standardized form or online system and is governed by a partnership between state agency representatives and the healthcare organization. However, the Joint Commission (TJC) requires accredited healthcare agencies to report sentinel events, defined as an unexpected occurrence involving death, serious physical or psychological injury, or the risk thereof. Patient safety can be improved by recognizing medical errors, learning from them, and working toward preventing them (ANA, 2021; Rodziewicz & Hipskind, 2019). 

Reducing Professional Risk Through Documentation 

To reduce the risk of medical errors, TJC created the "Do Not Use" list of abbreviations (see Figure 1). The list applies to all orders and medication-related documentation across handwritten, computer entry, and preprinted forms (TJC, n.d.). 

Most documentation errors are preventable if proper precautions are taken. Table 2 provides a compilation of documentation guidance. These documentation tips are designed to guide nurses in ensuring that every entry in the medical record reflects high-quality and safe patient care (Capriotti, 2020). 

Critical Thinking: Reflective Case Study 

Mr. Jones is a 42-year-old male patient with a past medical history of hypertension, diabetes mellitus, chronic pain, alcoholism, and clinical depression. He was admitted to the medical-surgical nursing unit for complications of uncontrolled diabetes. Mr. Jones has an open wound on the left lower extremity and is on intravenous antibiotics for a diagnosis of cellulitis. Mr. Jones requires daily wound debridement. Tara is the registered nurse assigned to the dayshift care of Mr. Jones and five other patients on the unit. During a shift change, Tara received a morning report that Mr. Jones was "non-compliant" with his medications throughout the night, refusing to take any medicines and ordering the nursing staff to leave the room. When Tara attempted to bring Mr. Jones his morning medications, including antihyperglycemics and antibiotics, Mr. Jones became acutely agitated and ordered Tara to leave the room. Tara tried to reason with Mr. Jones, explaining the risks of refusing his diabetes medications and antibiotics, including worsening infection and severe illness. Mr. Jones continued to refuse the medications and ordered Tara to leave. At that point, Tara decided to give Mr. Jones some time to rest and opted to administer medications and provide care to her other patients, with plans to return to Mr. Jones later. Tara returned to Mr. Jones's room about 2 hours later, and Mr. Jones again yelled for Tara to leave the room immediately. Frustrated, Tara called Mr. Jones's attending physician to alert them of the difficulties with administering medications. In the interim, another patient became acutely ill, and Tara's attention was diverted from Mr. Jones for the next few hours. Tara connected with the physician later in the day, who seemed unphased by the information. Concerned, Tara reached out to the nurse manager for assistance. 

Nearing the end of the shift, Tara realized that no documentation had been done on Mr. Jones throughout the day. Tara logged onto the EMR and completed the institution's required checklist-based nursing assessment flowsheet, intentionally leaving the physical examination section blank since the patient refused to allow the examination. At the end, Tara entered a short progress note stating, "The patient is grumpy and angry, yelling at nursing staff. The patient was non-compliant with care. No acute events or falls." Two days later, Mr. Jones became acutely ill with sepsis, as the cellulitis infection of the lower extremity progressed to a bloodstream infection. Mr. Jones was transferred to the intensive care unit (ICU) and died from cardiopulmonary arrest 24 hours later.  

Identify the red flags with Tara's nursing documentation and describe how Tara rendered themselves and the organization liable for a malpractice lawsuit. Finally, consider how Tara's documentation could be improved.  

Red Flags 

There are several red flags regarding documentation errors and omission of relevant data in this case. Some of these include: 

• Tara did not chart in real-time with each encounter but instead waited until the end of the shift.  

• Tara used subjective opinions and judgments instead of listing factual data in the notation. 

• Tara did not document the inability to perform the physical assessment. Instead, Tara left the areas blank, implying that this was not addressed or overlooked, which could be considered negligence. 

• Tara did not list the essential interventions performed to remedy the problem (i.e., notifying the physician, alerting the nurse manager, and educating the patient). 

Below are some examples of high-quality documentation that Tara should have included: 

• Medical Entry #1: "Attempted to assess Mr. Jones at 7:50 AM after receiving the morning report. Mr. Jones did not allow for a physical assessment to be performed and refused the morning dose of Metformin and penicillin." Tara Knight, RN, 9/29/19, 8:00 AM. 

• Medical Entry #2: "Re-attempted to assess Mr. Jones at 9:35 AM. Mr. Jones again expressed frustration with being disturbed and refused the Metformin and penicillin. I paged Dr. Harold at 9:45 AM and spoke to them about the patient refusing care and medications." Tara Knight, RN, 9/29/19 9:52 AM. 

• Medical Entry #3: Documentation of the nursing assessment flowsheet: 

  • N/A was selected for each physical assessment component. 

  • Free text notation was added: "Unable to perform physical assessment due to patient refusal. Dr. Harold paged at 11:45 AM and updated on the situation." Tara, Smith, RN, 9/29/19 11:55 AM. 

• Medical Entry #4: "Nurse manager notified about the inability to provide nursing care to the patient. This situation was discussed with Dr. Harold at 2:00 PM by telephone. The nurse manager spoke with the patient. The patient was counseled on the risks of refusing medical care and medications, including worsening infection and other health complications." Tara, Smith, RN, 9/29/19 2:10 PM. 

Discussion 

This case discusses many problematic issues related to nursing documentation. The scenario portrays Tara as being overwhelmed and burdened by the heavy nursing assignment and tending to sick patients, leaving little time to document. While Tara attempted to educate Mr. Jones on the risk of worsening illness and complications associated with refusing medications on more than one occasion, the communication exchange was never documented in the record. Tara also neglected to document that the physician was paged twice and that a phone conversation occurred. Tara did not document speaking with the nurse manager regarding this patient. Therefore, these actions appear to have never happened from a legal or medical review perspective. Tara's documentation is lacking and can be considered professional negligence, contributing to poor patient outcomes. It does not accurately depict the events of the day, the actions of the nurse, or the input of the healthcare team.  

References 

American Nurses Association. (2010). ANA's principles for nursing documentation: Guidance for registered nurses. https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf 

American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. 

Capriotti, T. (2020). Document smart: The A-to-Z guide to better nursing documentation (4th ed.). Wolters Kluwer. 

Craven, R. E., Hirnle, C. J., & Henshaw, C. M. (2021). Fundamentals of nursing: Concepts and competencies for practice (9th ed.). Wolters Kluwer.  

Edwards, G. M., (2017). Avoiding the mishaps in healthcare provision. Nursing & Primary Care, 1(5), 1-5. https://doi.org10.33425/2639-9474.1031 

Eltaybani, S., Mohamed, N., & Abdelwareth, M. (2018). Nature of nursing errors and their contributing factors in intensive care units. British Association of Critical Care Nurses, 24(1), 47-54. https://doi.org/10.1111/nicc.12350 

Gesner, E., Gazarian, P., & Dykes, P. (2019). The burden and burnout in documenting patient care: An integrative literature review. Studies in Health Technology and Informatics, 264, 1194-1198. https://doi.org/10.3233/SHTI190415 

Institute of Medicine (US) Committee on Quality of Health Care in America, Kohn, L. T., Corrigan, J, M., & Donaldson, M. S. (2000). To Err is Human: Building a safer health system. National Academic Press.  

Jacoby, S., & Scruth, E. (2017). Negligence and the nurse: The value of the code of ethics for nurses. Clinical Nurse Specialist, 31(4), 183-185. https://doi.org/10.1097/NUR.0000000000000301 

Joint Commission. (n.d.). Do not use list. Retrieved June 18, 2022, from https://www.jointcommission.org/assets/1/18/Do_Not_Use_List_6_28_19.pdf 

Lee, S., & Lee, M-S. (2021). Nurses' electronic medical record workarounds in a tertiary teaching hospital. Computers, Informatics, Nursing, 39(7), 367-374. https://doi.org/10.1097/CIN.0000000000000692 

McCarthy, B., Fitzgerald, S., O'Shea, M., Condon, C., Hartnett-Collins, G., Clancy, M., Sheehy, A., Denieffe, S., Bergin, M., & Savage, E. (2018). Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review. Journal of Nursing Management, 27, 491-501. https://doi.org/10.1111/jonm.12727     

National Academy for State Health Policy. (2015). 2014 guide to state adverse event reporting systems. https://nashp.org/wp-content/uploads/2015/02/2014_Guide_to_State_Adverse_Event_Reporting_Systems.pdf 

O'Brien, A., Weaver, C., Settergren, T., Hook, M., & Ivory, C. (2015). EHR documentation: The hype and the hope for improving nursing satisfaction and quality outcomes. Nurse Administration Quarterly, 39(4), 333-339. https://doi.org/10.1097/NAQ. 0000000000000132 

Rodziewicz, T. L., & Hipskind, J. E. (2019). Medical error prevention. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK499956/ 

Woods, A. B. (2019). Lippincott nursing procedures (8th ed.). Wolters Kluwer.