You Don't Need Another Documentation Course!

Is documentation the #1 thing that keeps patients safe and you from being involved in a malpractice suit? No. Nope.  Probably not even in the top 3. The number one thing that keeps patients safe (and avoids litigation) is you, the well-trained, critical thinking, patient-advocating nurse. If you’ve read my last article on the timing of documentation, you know I’m all about making documentation work for you...bend that ish to your will! But, there are a few more things we need to talk about with documentation, because I still get asked about it all the time.  It’s tempting to use documentation as an easy scapegoat when we have fears around patient harm and lawsuits (“It must be the documentation!”). Unfortunately, that’s not accurate and it’s become a favorite distraction. That doesn’t mean it’s not still a little confusing.  And you know what? It makes sense that it’s confusing! Not because documentation is inherently difficult or challenging, its because you get mixed messages all. the. time.  And the contradictory messages can leave us feeling unsure.  We simultaneously hear “Chart by exception” and also “Documentation is all you will have when a lawsuit happens.”  We hear “Tell the patients story” but also “No double-charting!” We hear “If it can go in a flow-sheet, then don’t write a note!” so we spend our days searching for that perfect flowsheet row, now somehow convinced that notes are wrong. And meanwhile, we slowly forget that yes, you do indeed know how to chart. You do, I swear! 

Along with the mixed messages, we also get scary messages all. the. time.  Case in point, I recently received an email advertising a course titled “Documentation to Avoid Litigation: Your Documentation May be All You Have” When I clicked on the course to see the cost ($139) it goes on further: “Documentation can save your life and your livelihood”.  Well, that sounds freaking terrifying!  Although courses like this are common, I think this one is special in that it packs in a total of 4 (FOUR!!!) completely untrue statements. Let’s look at each one of these outlandish, confusing statements and their variations because I see them a lot. But just so you know, they are meant to cause distress and encourage you to fork over your money.  

Fear-Based Claim #1: Documentation to Avoid Litigation

This plays to the fact that in healthcare in the U.S. litigation is an accepted reality in our professional lives and most nurses cite it as a fear that they have. The reason it’s not true is that there’s no documentation that you, the individual nurse, can do to POOF! prevent a lawsuit. Sadly, there are no magical words, phrases, techniques, or things to leave out that prevents an injury.  A birth injury case is about the care of many individuals operating within a hospital. Often, communication amongst a team is a factor and documentation is a component of communication, but it’s rarely the only or most important piece. Communication is cultural to a unit and there is a wide variety of acceptable ways safe communication happens. When I’m reviewing a case, I’m looking to see if the standard of care is met, not whether there was a progress note that could have gone in a flowsheet row. 

Let’s look at an example: There is tachysystole and late decelerations (documented) and the nurse continues to increase the Oxytocin (also documented, in the MAR). This continues for hours even as the tracing deteriorates and eventually, despite all the red flags, there is a prolonged bradycardia, crash C-Section and the baby has suffered from HIE.  Yes, I will point to the documentation as evidence that the standard of care was not met.  The documentation is not the problem. The actions and lack of physiologic knowledge of the nurse and the failure on the part of the hospital to adequately train its nurses or to support them in saying “No!” to some pit-pushing provider is the problem. There’s nothing this nurse could chart or not chart that would make the injury that happened not result in a malpractice claim.  So instead of documentation to avoid litigation, let’s make it “excellent patient advocates to avoid litigation”.

Fear-Based Claim #2: Your Documentation May Be All You Have

This statement is hinting at the old “In the court of law” refrain you hear from certain risk managers to scare nurses into being good little employees.  First off, I’ve been doing expert witness work for years, well over a hundred cases, dozens of depositions and I’ve never been to trial (“court”).  Typically, cases settle sometime between your deposition and trial. Second, I don’t even know what this means--all you have for what?? It’s not a shield protecting you from a zombie hoard. Not only is this classic fear-based language,  you, as a nurse, don’t even need protecting.  No harm is going to befall you.  Sure, this is stressful and having our care questioned is hard for any nurse.  Nurses can even experience trauma reliving the events of a likely memorable situation.  But your job during a deposition isn’t to protect yourself, it’s to help both sides, plaintiff and defense, gather information.  Your job is to share what you remember, what you did and why you did or didn’t do something.  Yes, you can look to your documentation, but you can also offer your memories of the events, whether actual vs refreshed, and your customary practice. 

Fear-Based Claim #3: Documentation Can Save Your Life

HAHAHAHAHAHAHAHA! I can’t.  This one is special...I’ve truly never seen that claim before.  

Fear-Based Claim #4: Documentation Can Save Your Livelihood

Again, your care is what is in question. Your care is what’s keeping you employed as a nurse Your documentation can be a way we get insight into the care you gave or didn’t give. Your deposition testimony can add new insights into how the hospital either supported excellent nursing care or fell below the standard of care in providing resources, education, training, staffing and a culture of safety.  Usually, your employment or licensure is not at risk because of a malpractice claim unless you were criminally negligent (like Nurse Death type stuff or drunk at work or something).  That’s a Board of Nursing issue and to be very frank, it takes a lot to get that revoked. 

There you have it! The four most common fear-based tactics and why they are so so wrong. Nurses, you are powerful! You are the number one thing that keeps patients safe in the hospital! But it’s hard to feel that way when we get this type of fear-based, very non trauma-informed, education put in front of us.  So please, the next time you are tempted to sign up for this kind of class, ask what you are really feeling scared or unsure about and lets talk about that.  You don’t need to give your power away, I know you know how to document.  If you don’t believe me, then stay tuned because I will show you that you are already super smart and know how to chart in the next article. And I want to know, what’s some of the stuff you’ve heard about documentation?