Nursing Documentation 101

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The following course content

This course is designed to give learners an overview of the best documentation practices for anyone in healthcare who contributes to a client’s medical record. Primarily, this course is geared toward the most common healthcare workers in the medical profession: nurses. This extends from nursing assistants and licensed practical/vocational nurses to registered nurses and advance practice registered nurses. The course will cover the reasons why documentation is important to client care, but also to protect the healthcare worker’s license. It will give examples of how assessments, procedures, and actions should be documented, as well as what should be avoided. 

Introduction 

“I just love charting,” said no nurse, ever. If you ask most people why they want a career in healthcare, their response is that they wanted to help people. They did not want to spend hours in front of a computer clicking boxes. This time-consuming task of documenting in the medical record, or charting, is dull, repetitive, and sometimes distressing. It takes time away from being able to provide care for the client. Yet documentation in the medical record is truly a vital part of client care. 

Nursing documentation fills a significant portion of the medical record. Nurses need to make sure what they are adding is accurate and complies with the guidelines set by their facility and the state board. This principle is the same, even though there are differences to be aware of now that the electronic medical record has become the standard. 

The Who, What, When, Where, Why and How of Documentation 

The “Who” of Documentation 

There are approximately 3.2 million working RNs in the United States, with about 1.75 million working in hospitals [1]. Nurses on a med-surg unit typically spend at least 20%-50%of their total working hours documenting and reviewing medical records [2][3]. Considering a nurse on a med-surg floor conservatively spends about 2.5 hours per shift charting, that roughly translates into 7 billion hours spent documenting each year. And that is only for the nurses! [1][2][3] 

Every discipline of the healthcare team contributes to the client’s medical record. These different clinicians may not have the opportunity to report off to one another, and they must refer to the medical record to gather the information they need in order to care for the client. Even kitchen staff responsible for preparing meals for clients must be able to see the dietary order for the client. The following are a few examples of the clinicians who contribute to or review the client’s medical record: 

• Medical Team: physicians, nurse practitioners, physician assistants, surgeons, specialists, residents 
• Nurses and LPNs 
• Medical Assistants, CNAs, client care assistants or technicians 
• Specialty technicians: radiology, anesthesia 
• Therapists: physical, speech, occupational, respiratory 
• Phlebotomists and Lab technicians 
• Pharmacists 
• Dieticians 
• Case managers or social workers 
• Chaplains 
• Coding and billing specialists 
• Regulatory Agencies: Department of Health, Joint Commission, etc. 
• Researchers 

The “What” of Documentation 

The primary purpose of the medical record is to communicate data about the client and care provided between different members of the healthcare team [4]. The bulk of the medical record is a collection of assessment data obtained from the client. Details concerning assessments and results from diagnostic tests a large portion of the data. Assessment data is usually collected on a flow sheet system. Everything from trips to the bathroom to major cardiac arrests must be documented. Progress notes are written by the medical team, or therapists help to guide the intended plan of care for the client. This is considered narrative documentation. The medical record also includes orders for prescribed medications and treatments from the medical team. The following are typical components found in a client’s medical record: [4] 

• Client demographics: name, age, sex, gender identity, contact information, language, insurance information. 
• Past medical history: surgeries, chronic conditions, family history, allergies, home prescriptions. 
• History and Physical (H&P): this can contain information about admitting diagnosis or chief complaint and narrative of the story leading to admission. 
• Flowsheet of assessment data: vital signs, head-to-toe assessment, intake and output record. 
• Laboratory test results. 
• Diagnostic test results: from radiology or procedures. 
• Clinical notes: progress notes from the medical team, procedure notes, notes from consulting clinicians, education provided, discharge planning. 
• Treatment Orders. 
• Communication and topics discussed with the client. 
• Medication Administration Record (MAR). 
• Social Determinants of Health: These are non-medical factors that impact health. As a part of the United States Office of Disease Prevention and Health Promotion’s Healthy People 2030, these are new a major focus. The five areas included are: economic stability, education access, healthcare access and quality, neighborhood and environment, social and community support. If they haven’t already, healthcare workers can expect that they will need to also assess clients for each of these areas​ [5]​.  

The “When” of Documentation 

The medical record should include every interaction the client had with a member of the healthcare team. A record is created upon admission to each healthcare facility and everything occurring during a particular admission becomes part of the medical record. Medical records for clients in a critical or inpatient setting must be kept updated constantly throughout the shift. Other clinicians need to be able to see care provided or status updates and may base their treatment decisions based off what they find in the chart. [4] 

Busy medical clinicians are often challenged to ‘chart as they go’ throughout the day. Pressing needs of client care must always come first. Documenting may have to wait when there is a change in a client’s status or a surprise admission. When there is some downtime, it is very poor practice to procrastinate documentation. Clinicians are more likely to have omissions of data if they wait until the end of shift to catch up on documenting. Utilizing time wisely to complete documentation is an essential time-management skill. If a clinician has a pattern of late documentation, managers may have to have corrective action plans with that staff member. [4] 

The “Where” of Documentation 

Medical records are stored in various ways depending on their format and the facility. Paper records from small outpatient offices may be kept onsite. Records are now largely kept electronically. This is referred to as the electronic medical record (EMR) or electronic health record (EHR) and consists of Protected Health Information (PHI). They will be stored on a secure server, typically only accessible by authorized personnel. Data also is encrypted, especially when transmitted outside of the healthcare facility. ​[6]​ 

The “Why” of Documentation 

The medical record is essential for several reasons. The primary reason for the medical record is that it allows members of the healthcare team the ability to review and analyze data in order to deliver appropriate care. It allows clinicians to keep track of all the care that has already been completed for the client. It also provides the client with a record of the treatment they received as part of their lifetime medical history. The medical record is used for coding and creating a bill for the services the client received. Medical records may also be used for process review and research. Ultimately, it is also a legal document and may be used in a court of law as applicable. [4] 

The “How” of Documentation 

Medical records are in the final stages of evolution from a paper chart to an electronic medical record (EMR) or electronic health record (EHR) system. The first EMR was developed in 1972 [3]. By 2021, 96% of acute care hospitals and 78% of physician offices possessed certified EMR [7]. This migration of medical records from paper to electronic format was made possible with advances in technology, especially in the last 30 years. The EMR allows members of the healthcare team to access the medical record instantaneously and improves continuity of care. Utilization of the EMR ultimately reduces costs in healthcare and increases efficiency [3][7][8][9]. 

While EMR does have some drawbacks, the benefits that it provides are substantial enough that the government has encouraged its adaptation. The Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted in 2009. This program provided tens of billions of dollars in financial incentives for healthcare facilities to adopt an EMR system [3][7][8][9][10]. 

Technology and Medical Records 

Benefits of the Electronic Medical Record (EMR) 

• Immediate data accessibility and communication of client status. [3] 
  • Clinicians can view records remotely, analyze the findings, and place orders immediately for faster client treatment. 
  • Multiple clinicians can view the medical record at the same time. 
  • Records can be viewed from previous admission and/or outpatient visits easily. 
  • Records can be instantly shared between facilities (in instances of connected EMR systems). 
• Reduction in errors. [3] 
  • Errors due to misinterpretation of handwriting are eliminated. 
  • Allows for increased safety checks. The EMR can be set to flag missing components of information, tasks that were not yet completed or are overdue, recognize duplicates, and present warnings if documentation has not yet been validated or “signed.” 
  • Barcode scanning medications are possible with EMR systems to reduce the risk of medication administration errors. 
• Assists with appropriate billing by capturing charges of services provided to the client. [3] 
• The EMR can provide reminders for necessity of certain preventative health screenings or vaccines. [3] 
• Automatic “signature” of data is completed simply by the user logging in with a unique ID and password. All entries are date and time stamped. If a correction is made, the original data can be accessed. [3] 
• Accessing client EMR is tracked and can be audited to protect client privacy from unnecessary viewing. [3] 
• No more time spent hunting down your favorite pen someone ‘borrowed’ and never returned! 

Downsides of the Electronic Medical Record (EMR) 

• It is expensive to convert record systems to an electronic version. [3][11] 
  • The initial cost of the EMR software is very expensive. Changing EMR systems or performing upgrades is also costly. 
  • More workhours must be paid for staff training and coverage of clients during initial implementation of the program. 
  • Maintaining appropriate encryption and cybersecurity technology against viruses and hacking are also a costly component. Facilities also need to pay for cyber security insurance premiums. 
• Computer systems can be temporarily inaccessible, for example when updates and reboots are required. Paper documentation is still necessary in the interim. Clinicians unfamiliar with paper charting are at high risk for errors and omissions. [3][11] 
• Template documentation has limitations. [3][11] 
  • Templates may not exist for a specific problem and do not accurately reflect the client’s condition. Atypical clients may have multiple problems or extensive interventions that must be documented in detail. 
  • Templates may also encourage cloned or copied documentation. It creates unnecessary redundancy and at times inaccurate information in the EHR. Some EHR systems are designed to facilitate cloning with such popular features as: Duplicate Results” to copy forward assessment data or “Smart phrases” pulls in specific identical data elements. 
  • Automated insertion of previous or outdated information through EHR short-cut tools can raise quality of care and compliance concerns. 
• Perceived reduction in client interaction. Many clients and veteran healthcare clinicians feel that having to face a computer screen impedes the personal connection made with the client. A small clipboard or binder was much less intrusive than a large monitor or a ‘workstation-on-wheels.’ [3][11] 
• Clinicians can also feel that there was an increase in documentation requirements and workload with the introduction of EMRs. [3][11] 
• There has been increased burnout and decreased job satisfaction with healthcare clinicians which has coincided and increased with integration of ERMs [3][11]. 

Documentation and Artificial Intelligence (AI) 

AI is rapidly evolving and integrating into many aspects of our world. Sometimes, AI may already have been implemented behind the scenes with us being none the wiser. Time will tell how quickly the healthcare industry will see these new advancements implemented. Here are some of the most likely features that will soon be widespread: [11] 

• Voice-to-text dictation and virtual scribes 
• Power chart summarization – Summarizes long medical history from multiple notes and records. 
• Automatic correction and suggestion tools – Provide for potential diagnoses and more accurate billing. 

Protected Health Information / Privacy and Security 

Since 1996, HIPAA, The Healthcare Information Portability and Accountability Act, has been the governing legislation that provides for the privacy protection of medical records. HIPAA legislation was introduced at the advent of EMR technology. It includes safeguards needed to protect PHI, as well as the consequences of not following these laws. The consequences usually include hefty fines but may also include criminal charges. [9] 

Compliance with HIPAA mandates that anyone who interacts with clients and medical records receive training that will ensure that they will maintain privacy for the client PHI. Employees at any medical facility, from a small physician practice to a large hospital corporation, will typically need to undergo HIPAA training upon hire and annually thereafter. Even individuals who never have contact with a client need to understand HIPAA laws and regulations. This includes billing personnel, health insurance companies, and IT support companies. Other outside hospital vendors, such as temporary construction workers, equipment installation, or terminal cleaning personnel may require training since they may need to work in restricted areas and may accidentally see PHI. ​[9]​ 

There are three main areas that govern the required types of protection: administrative, physical, and technical safeguards. These safeguards become naturally ingrained in everyday functions of healthcare providers. Some examples include the following: [9] 

• Special locks on restricted areas that must be opened by keys, codes, or badge scanners. This may include record storage, offices, or even nursing stations.  
• Security personnel, cameras, and visitor logs. 
• Covering any papers, charts or documents when they are not in use.  
• Using complex passwords to enter EMRs and requiring regular password changes. Automatic application log outs. 
• Encryption on external data storage devices such as thumb drives, or data transmitted over email. 
• Special computer screen covers that prevent ‘over the shoulder’ viewing.  

Retaining Medical Records 

Medical records also need to be kept for many years. The length of time medical records need to be maintained can be determined by federal and state law, or accreditation agencies such as the Joint Commission ​[12]​. The length of time is often dependent upon the laws governing malpractice statutes of limitations. The statute of limitations refers to how long a person can file a lawsuit (sue) against another party for harm they suffered. This time period may vary based on the practice setting, and the client population. The following are a few examples: [12][13] 

• A small doctor’s office in Florida may only need to keep records for each client visit for five years after the client’s last visit.  
• A doctor’s office in Georgia would be required to keep records for ten years since the records were created. 
• In North Carolina, a hospital must maintain client records for seven years since the date of discharge. If it was a pediatric client, they must keep the records until that person has reached 30 years of age.  
• Healthcare providers in Nevada need to keep records for a minimum of five years, but they need to keep pediatric client records until the client is age 23. ​[13]​ 

Since there can be many different stipulations as to how long each record needs to be kept, it can be easy to see why some institutions may choose to keep all records beyond the minimum requirement.   

Medical Records Disposal 

Even cleaning is not as simple as throwing things in the trash! When it is time to discard records, they must also carefully be destroyed. “In general, a covered entity may not dispose of PHI in paper records, labeled prescription bottles, hospital identification bracelets, PHI on electronic media, or other forms of PHI in dumpsters, recycling bins, garbage cans, or other trash receptacles generally accessible by the public or other unauthorized persons.” ​[6]​ 

“For PHI in paper records, shredding, burning, pulping, or pulverizing the records so that PHI is rendered essentially unreadable, indecipherable, and otherwise cannot be reconstructed.” ​[6]​ For paper documents, most facilities have large ‘shredding’ collection bins that are serviced by a professional disposal company. There also be tedious measures that require staff to remove or cover client labels from medication containers (IV bags, syringes, etc.) before disposing of them. Facilities also need to have policies on how to destroy other external electronic sources, such as CD’s, DVD’s, thumb drives. An Information Technology (IT) specialist will be needed to handle any large destruction of EMR items contained on cloud or server-based storage. [6] 

Medical Records and Crime 

Despite safeguards a facility may use, reaches in security by hackers or cyberterrorists remains a potential threat. These cyber criminals may gain access to PHI and may hold it ransom. “Ransomware is a type of malware (malicious software) designed to deny access to a user’s data, usually by encrypting the data with a key known only to the hacker who deployed the malware, until a ransom is paid.” ​[14]​ Cyber criminals may also gain access to PHI during a data breach and threaten to disclose or sell the data unless the facility pays the ransom. Since 2018, there has been a 264% increase in large breaches reported to OCR involving ransomware attacks.”​ [14]​ 

Facility employees who have been granted access can also commit crimes if they access PHI that is not required for their job duties. Some examples of this can include: [14] 

• A celebrity client is giving birth at a hospital, a staff member working on the oncology floor views the record and sells the PHI to a tabloid magazine. 
• A healthcare worker is anxious to receive their pathology and lab report from a recent procedure, and they view their own medical chart.  

In the above example, it is obvious that selling information will lead to serious problems including criminal charges, legal fines, and termination. However, even looking at your own medical record without going through the proper medical record request channels can also result in being fired.  

Client Rights to Protected Health Information 

Part of HIPAA legislation requires that clients have the right to request their medical records. The client also has the right to request to amend their medical record. Client permission must be given prior to a third party’s access to their medical record. Some examples of when a third party may request medical records may include the following: [15] 

• A life insurance company determining a policy and premium for a client. 
• An attorney requesting records when determining damage incurred in an auto accident. 
• A job that has physical requirements, such as an eye exam for a pilot 

Documentation Content Requirements 

If it wasn’t documented, it wasn’t done. Every healthcare practitioner has had this mantra ingrained in them from the very beginning of their career. Nurses are trained to document defensively.  It is not uncommon for clinicians to have the tendency to view the medical record as a defense tool against potential legal problems, rather than its more significant role as a communication tool for client care.​ [4]​ 

Regardless, accurate and complete documentation is essential. Your career, and more importantly, client care, depends on it. 

When Documentation Becomes Your Defense 

In the dreaded event of a legal problem, medical records will be scrutinized for every detail. Medical records factor into 10-20% of medical malpractice lawsuits. ​[16]​ A malpractice lawsuit requires four elements to be proven: [17] 

• That a medical professional or entity assumed a duty to provide care for the client. 
• The clinician failed to provide appropriate care within their scope of practice for the client. 
• The failure to provide appropriate care caused an injury to the client. 
• The injury resulted in damage to the client. 

Common areas where documentation can negatively impact the healthcare worker in a malpractice lawsuit include some of the following: [16][17] 

• Incomplete or missing documentation 
• Inaccurate text 
• Transcription errors 
• Judgmental language 

Costs 

The majority of medical malpractice cases primarily target the physician and the facility. However, anyone who made an entry into the client’s medical record may be required to participate in legal proceedings. [18] 

Most common malpractice claims against nurses include failure to: [18] 

• Failure to follow standards of care: 
• Follow safety protocols. Example: A nurse does not utilize a gait belt when assisting a fall risk client to ambulate. 
• Perform procedures according to guidelines. Example: A nurse does not follow facility guidelines for flushing a gastric tube with water after administering medications. 
• Failure to use equipment properly.  
• Use or operate equipment within the manufacture’s details. Example: A nurse in the post-anesthesia care unit uses a forced air warming device (e.g. Bair Hugger) without the attached disposable blanket, because the blankets are expensive.  
• Failure to correctly document: 
• Communication with the provider. Example: A nurse fails to report abnormally high potassium lab result. 
• Care completed: A client is given a PRN medication but it was not documented. The client then received a second dose of that same PRN medication by nurse covering a lunch break. 
• Failure to assess and monitor.  
• Assess a client with a change in status. Example: A client has decreasing oxygen saturation levels, and the nurse does not take action.  
• Report a change in status to the physician Example: A night shift nurse does not wish to wake up the on-call physician to update them about a client’s increasing blood pressure. 
• Communicate pertinent data. 
• Provide appropriate discharge education and information. Example: A nurse does not inform a post-operative client about activity restrictions prior to discharge. 
• Communicate properly and completely between shifts. Example: A nurse does not include in the report that the client has a latex allergy. 

What is Required for Nursing Documentation? 

Necessary medical record documentation can vary significantly depending on the care area. For example, the documentation a circulating nurse in the operating room completes will be very different from what is documented on an emergency room client. While the basic principles of documentation stay constant, the nurse needs to be familiar with the documentation requirements for that area based on requirements of the state board of nursing, the facility, and the unit. [4] 

There are standard requirements for medical record documentation that are applicable in all client care settings, and in both paper and EMR systems. These standards include the following: ​ [4]​ 

• Accurate: Clinicians must be careful to proofread documentation to make sure it is free from errors. A small typo can have serious repercussions, as it is more likely to be misinterpreted by others. 
• Relevant, concise, organized and complete: It is important to keep the information concise and relevant so that other clinicians can quickly find the pertinent information that they need. Assessment data should be entered in a systematic way. Complete documentation ensures all of the unit policies for documentation are addressed. 
• Free of bias: Clinicians should only include information that is pertinent to the care of the client and remain free from personal bias. Direction quotations should be utilized with proper context. 
• Factual: Clinicians should not exaggerate or minimize findings. Documentation is to be completed after completing a task, not before. Do not speculate data. Observations need to include exact times and measurements. Avoid approximations. Make sure to chart on the correct client. 
• Timely: What occurred during the shift should be documented during the shift. Documentation should be done as soon as possible after task completing. If something needs to be added in after the shift was completed, it should be denoted as a late entry with a reason as to why. Your facility likely has strict requirements regarding late entries. 
• Legible/decipherable and clearly written: Paper documentation must be clearly legible. Writing must clearly convey meaning. Scanned documents must have clear resolution. 
• Standardized: Clinicians must use appropriate medical terminology and approved acronyms and abbreviations.  
• Labeled and Auditable: Paper documentation must be signed with credentials and must include date and time of the entry. When documentation in the EMR, all entries and corrections are recorded, and time stamped. Password sharing or having another clinician assist in documenting under incorrect username is fraudulent. 
• Accessible: Documents must be able to be located and retrieved so other clinicians, clients requesting records, and accreditation agencies can view the records.  

Examples of Good and Bad Nursing Documentation 

The following will show some examples of these principles in action. These are based on the scenario of a client admitted in the Emergency Department for chest pain. [4] 

​Common Documentation Errors 

• Falsification of a record. This can happen from documenting an action that was never done, or from documenting information before the action was completed. [4] 
• Fraudulent documentation is the act of knowingly making a false record. Criminal charges of forgery can result if the misrepresentation was done for personal gain. An example of this would be a nurse documenting administration of controlled substance but instead diverting was the medication. [4] 
• Inappropriate use of cloning features. Information “copied and pasted” from a different client’s record or that was completed by another clinician. Data copied from previous shift assessments that aren’t updated to reflect current status is also a false record. [4] 
• Failure to document communication. Notification of the medical team of a change in client status or critical lab values should always be included. Clarification or confirmation of orders should also be documented. Include notification of other clinicians who assisted with client care. This includes failure to document transfer of care to another nurse. [4] 
• Failing to document a reason why something wasn’t done. If a client doesn’t receive a prescribed medication, the reason why the medication wasn’t given needs to be described. If you communicate with the clinician, this should also be included. [4] 

Conclusion 

Including all of the necessary information into each client’s medical record is a daunting task. The nurse must make sure that they have included all of the relevant and accurate information that is required by their facility guidelines. It must usually be done in a loud environment and is frequently interrupted by actually having to provide care to the clients. 

It is not only a tedious chore, but it also tends to cause a lot of apprehension. There is usually a worry of “did I chart enough?” or “did I chart everything I needed to?” This is due to the defensive practices and attitudes healthcare workers have adopted to protect against malpractice lawsuits. In this way, charting is a lot like paying taxes. No one likes it, but it still has to be done. 

Perhaps a way to develop a healthy perspective toward documentation is to change the focus back to its original purpose: to communicate care about the client. The purpose of documentation is to relay to the other healthcare team members what is going on with the client. With this objective in mind, the nurse will inevitably cover all the necessary details. It may also be a bit more satisfying to know that even though they are in front of the computer, they are still doing something important for the client. 

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