nursingforsocialjustice

I am interested in clinical documentation. Clinical documentation is important. It allows for continuity of care, and is a legal documentation that supports the assessments and interventions that have been completed. I think that it is important that we think of clinical documentation as both as reflection of the care that we are giving, as a clinical record and also about the utility of if in terms of providing better care. I think we constantly have to ask ourselves, what is the point of the information that I am recording?  Is there useful information contained in this documentation? How would a third party reader, someone that is not part of my team understand the information that I have recorded?

We also need to understand which documents are part of the patient/client’s chart and which are not. Informal emails, clinical support tools that are shredded, documents that contain information for multiple clients/patients are not part of the patient’s chart. It is important that we remember this, because, if some adverse incident happens and we are required to testify in court we rely on the information that we have documented being an accurate reflection of the care that we have given.

Wanting to reflect the patients voice is important. It is not so important (perhaps even detrimental) to include a subjective opinion of how much or how little we enjoyed en interaction with a patient. Notation like “great session” or “awesome visit” is a reflection of our subjective experience of an interaction. Is it important that other clinicians know this information?

Peace,

Michelle D.

References

Alex, M., Whitty-Rogers, J., & Panagopoulos, W. (2013). The language of violence in mental health: shifting the paradigm to the language of peace. Advances in nursing science, 36(3), 229-242.

Barloon, L. F., & Hilliard, W. (2016). Legal Considerations of Psychiatric Nursing Practice. Nursing Clinics of North America, 51(2), 161-171.

Blair, W., & Smith, B. (2012). Nursing documentation: frameworks and barriers. Contemporary nurse, 41(2), 160-168.

Christopher, B. A., Flood, S., Carlson, E., Delaney, K., & Krch-Cole, E. (2011). Standards of care: are they being used?. Journal of nursing care quality, 26(3), 273-278.

Donohoe, J. (2015). Implementing an Education Programme and SOAP Notes Framework to Improve Nursing Documentation.

Klingshirn, J. (2015). Creating Adaptable Behavioral Health Patient Environments (Doctoral dissertation, University of Cincinnati).

Okaisu, E. M., Kalikwani, F., Wanyana, G., & Coetzee, M. (2014). Improving the quality of nursing documentation: An action research project. Curationis, 37(2), 1-11.

Smith, J. L. (2015). Barriers that prevent nursing staff on a non-critical care unit from effecting individualized documentation of patient care plans.

Vabo, G., Slettebø, Å., & Fossum, M. (2016). An Evaluation of an Action Research Nursing Documentation Project. Journal of clinical nursing.