If It’s Not Documented, It Was Not Done

How many times have you heard this “If it’s not documented, it was not done?”  I assume many and it is so true. Your documentation will save you every time.  Some common areas where lack of documentation becomes concerning include: 

1. Failing to document Verbal Orders.  It is imperative to document verbal orders.  I hear it all the time from ER nurses that they forgot to document the verbal order.   If that verbal order was not documented, it looks like theft and practicing medicine without a license because medication was taken out of the Pyxis without an order and given to the patient.
2.  Questioning Provider Orders.  I was taking care of a patient who had an order for Bumex in a large dose.  I questioned the physician about it and he said it was the last chance to avoid dialysis to get her kidneys working with this large dose of a diuretic.  I felt comfortable giving it but if I had not documented the conversation, that could have been trouble for me if something happened to the patient.
3. Failing to go up the Chain of Command.  If the physician in the above matter did not give me a good explanation for the large dose, I needed to go up the chain of command.  Many times, nurses are afraid to go up the chain but it is necessary and needs to be documented to protect yourself.
4. Failing to Document Timely vital signs.  Unfortunately, with electronic medical records, the time you document is the time on the record so if you are documenting something late, be sure to enter it as a late entry.  This may raise a red flag too but is better than not documenting.
5. Reporting of changes in condition.  If you do not document a change in condition and what you did about it can also be problematic.
6. Medications Given.  Again, if you do not document medication given, it can be considered theft.  There are many steps to giving narcotics such as taking it from the Pyxis then scanning the patient’s wrist band that the medication was given.  Don’t forget this step and if the scanners are down or the EMR is down, make sure it gets documented. 
7.  Patient Response to Medication.  Let’s say the count was off for Norco and you gave a Norco to a patient.  Now you are being accused of taking the Norco but if you document the patient’s response and if the patient says she never received the Norco, this will help protect you.
8. Discharge Teaching.  If your discharge teaching includes when to call the doctor and it is not documented and the patient does not call the doctor, then it falls back on you. You are liable.

Nurses are so busy and the last thing we want is to stay late to chart but if you document it today, it will save you a bunch of headaches in the future!