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Strategies to improve nursing documentation* The form your facility chooses makes a difference in the quality of documentation


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Learning objectives: After completing this exercise, you will be able to:
1. identify the advantages and disadvantages of narrative documentation
2. describe the benefits of using checkbox/template documentation
3. recognize electronic documentation's strengths and problems

When deciding which type of form to use for nursing documentation, first weigh the inherent positives and negatives of each general type--narrative, template, and electronic.

Above all, documentation forms must be efficient, comprehensive, and reasonable, and must prompt nurses to document appropriately, says William Malm, ND, RN, president of Health Revenue Integrity Services, Inc., in Cleveland. For some documentation do's and don'ts, click here. And for some common mistakes to avoid, click here.

Narrative documentation
A narrative documentation form is essentially blank and the nurse simply writes in all of the pertinent information. These types of forms are based on the SOAP (Subjective, Objective, Assessment, and Planning) template. This is the least effective form because it is completely up to the nurses to decide what they document, Malm says. In addition, this form is not easy or efficient to use, because nurses must write everything out, rather than simply checking boxes next to descriptions of the services provided. "It's very inefficient and leads to a lot of documentation errors," says Malm. However, narrative forms are flexible, especially for documenting complications, new diagnoses, and other unforeseen occurrences.

Checkbox/template documentation
A template form of documentation--which usually combines a string of checkboxes with an area for narrative notes--is a convenient, efficient, and comprehensive approach. Because nurses can simply check boxes as they provide care, these forms also remind staff what they need to document. The addition of a narrative area allows nurses to make extra comments about the care or any unforeseen complications.

"The checkbox method is the most efficient by far, because you can just go down the line and see the whole thing--it's not on separate pages or on a computer," says Malm. "It allows you some more flexibility but still leads the nurses to complete it in the same fashion, thereby ending up with the data that you require."

But even checkbox documentation has limitations when it's paper-based. "[With a] paper chart, I've got medical records, the respiratory therapist, the physician, the physician's assistant, [and] the nurse. All of those people are going to want that medical record at the same time," Malm adds.

Electronic documentation
Despite the fact that many hospitals have not yet made the transition to electronic health records (EHR), Malm says he prefers this means of documentation for several reasons. First, you can customize EHRs to capture whatever information your facility deems necessary.

Although electronic documentation presents flexibility problems (e.g., once set up, electronic documentation templates can be difficult to alter), it promotes the capture of uniform documentation.

Although the cost associated with transitioning to an EHR can be a drawback, it eliminates filing loose paper and retrieving records. Read about the learning curve here. EHRs are optimal for dealing with litigation, audits, and patient care, Malm says. With paper records, medical records and health information management have the burden of maintaining, filing, and retrieving charts as well as tracking the paper records' location when in use. EHRs comply with Health Insurance Portability and Accountability Act of 1996-related requirements and provide appropriate caregivers access to the records, says Malm.

"With the paper method, the physicians have the charts, and you may not have that immediate opportunity to document, so you forget it or don't do it," says Malm. "With an EHR, you just go to a computer screen and view the chart. Everybody has access immediately, which makes the process more efficient and prevents lost documentation, [which is a] key to exceptional clinical care, fundamental reimbursement, and litigation support."

Source: Briefings on APCs, September 2006, HCPro, Inc.

Resources:
1. "Do's and Don'ts of Nursing Documentation" at http://medi-smart.com/documentation.htm
2. "8 Common Charting Mistakes To Avoid" at http://www.nso.com/newsletters/features/common.php
3. "Software Simplifies Charting, but There's a Learning Curve" at http://news.nurse.com/apps/pbcs.dll/article?AID=/20070226/PHILADELPHIA09/702260305/1009/PHILADELPHIA


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