Document it

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We all know how important documentation is, but I really found it out yesterday.  This showed me that old saying of “if you didn’t document it, it didn’t happen” was really true.

I am not talking about documenting patient care stuff, although you will see with my example that it applies the same way.  This was about an employee issue that I inherited from my predecessor and finally dealt with myself.

When I started there was an RN on this unit that I was told was pretty incompetent.  She had received multiple annual evaluations stating she needed improvement in many areas over the previous couple of years.  She had been placed on multiple performance improvement plans and had been placed back on orientation several times.  Honestly, she should have been let go long before I got here.

A couple months into my tenure, she made three huge medication errors and a huge patient care error….all in one shift.  I immediately placed her on suspension so I could investigate what happened.  What I found was that these errors were all errors she had made the past, and in talking to her, she really had no idea that she did anything wrong.  So, I terminated her employment, and because of her errors, it was required that she be reported to the Board of Nursing (BON).

I received a letter from an investigator from the BON wanting to talk to me, review her employee file and any medical records that could substantiate the information in the complaints against her.  He also wanted to talk to anybody that was involved in these incidents during her employment, i.e. charge nurses, preceptors, etc.

I collected all the information and people he requested and met with him yesterday.  He began asking questions about incidents that happened over four years ago.  I was not here so I had not idea, and there was absolutely no documentation to back up the allegations the previous manager had made, and those that were there and involved could not remember what happened because it was so long ago.  It really made the previous manager look bad.

When it came to the information he wanted related to my disciplinary action and eventual termination of her, I was able to provide information to back up my claims such as the MAR, nurse’s notes and physician orders that showed exactly what happened.  This was because when I actually terminated her, I had everything printed, copied and in the file so I could remember what happened by looking at the documentation several months or years later.  I also wrote notes in her file to explain what had happened.

This goes for your documentation on your patients to… need document enough on you patients now so that when you are on the witness stand in court ten years from now, you can tell a lawyer exactly what you did and why.

Read “Documentation…What Were You Thinking?” for more thoughts on documentation, and how it’s a reflection on you.

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Rob Cameron

Rob Cameron is currently a staff nurse in a level II trauma center. He has primarily been an ED nurse for most of his career, but he has also been a nurse manager for Surgical Trauma and Telemetry unit. He has worked in Med/Surg, Critical Care, Hospice, Rehab, an extremely busy cardiology clinic and pretty much anywhere he's been needed.Prior to his career in nursing, Rob worked in healthcare finance and management. Rob feels this experience has given him a perspective on nursing that many never see. He loves nursing because of all the options he has within the field. He is currently a grad student working on an MSN in nursing leadership, and teaches clinicals at a local university.Away from work, Rob spends all of his time with his wife and daughter. He enjoys cycling and Crossfit. He is a die hard NASCAR fan. Sundays you can find Rob watching the race with his daughter.

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4 Responses to Document it

  1. i completely agree. i document a great deal, and the other nurses always make jokes, calling me the “documentation queen”, however, i am covering my backside, as well as protecting the facility i work for, and ensuring that all nurses that may care for this patient after me knows from a to z exactly what is going on with this patient. i have seen alot of incompetence in documentation. they need to make this a more serious instruction for our nurses-to-be.

  2. Norman

    I think that we should separate the hospital from the business. At the top of the hospital is business and at the bottom promises and oaths. Too many different rules and laws governing too many disciplines.
    This leads to some of the problems we face, (i.e. charting problems, not all of course). The employer has to work on the real purpose of hospitals and that is helping patients get better. 1st, by shortening Nurse to Patient ratios. What it is now is ridiculous.

  3. Rob Cameron

    You can’t separate the hospital from the business. The hospital is what generates the revenue to pay the bills, pay your salary, provide any charity care, etc. It is all one in the same.

    The hospital can lower your nurse to patient ratios, but that does not change the regulations placed on all our jobs by regulatory agencies.

  4. I have been a LVN for 20+years. In texas the only thing an RN can do that a compident LVN cannot do is
    Charge, and Admission Assessment (ways arround that too) The pt to nurse ratio is outragous–and yet–
    errors are never tolerated (I work nicu,pdicu,and all childrens services) I consider privileged to care for the
    most presious things in a families life. It would be refreshing to be able to provide “quality” nursing care
    like it used to be.