Documentation In Nursing Documentation

1.0 Introduction Nursing and documentation are inseparable. Documentation or sometimes called as reporting, charting or recording is defined as “any electronic or written information data about client interactions, care or events that meet both legal and professional standards (College of Registered Nurses of British Columbia, 2013). Nursing documentation includes everything involved in the patient’s care such as progress notes, assessments, nursing care plans, as well as letters written to and about patients, and written communication between colleagues about patients. According to Harrion (2001), nursing documentation is an essential responsibilities of all health care providers. It is a means of communicating among health care team and

Warren and Creech-Tart (2008) discussed that fatigue experienced by health care provider is one of the contributor factors to deficiencies in documentation. Since some health care providers work long hours and have demanding client assignments, they may not have clear thinking processes required during the process of documentation. Illegible writing is one of the most common complaints in written documentation as a result of messy handwriting (Rodríguez-Vera, Marín, Sánchez, Borrachero, & Pujol, 2002). A messy handwriting may occur if the nurses write the notes too quickly in order to save time or too many workloads on the same time. Messy handwriting can lead to misinterpretation of information and cause poor nursing care. For members of the health care team, trying to read the messy handwriting report can be a nuisance, sometimes requiring the assistance of colleagues to interpret it. Once the clients’ information is recorded, the nurses may ask other colleagues if they can easily read the hand writing. Besides, some of the health care providers also fail to read pertinent health or medication information accurately when poor handwriting is concerned. Again, illegible writing impacts the care because this step is important as past health history related experiences or medications prescribed assist the health care team to make the

For example, during the morning shift handing over, when nurses unable to digest what was written by doctors or nurses in the patient’s progress note, he or she might skip that order, plan or information. Hence, it will be lacking in information which in the end leads to poor clinical care (Rodríguez-Vera et al., 2002). Besides, from the patient 's perspective, illegible handwriting can delay treatment and lead to unnecessary tests and inappropriate treatment which, in turn, can result in discomfort and death. Illegible handwriting in medical records can also result in medical error. A patient aged 42 years old died when the prescription of 20 mg Isordil, an antianginal drug, order by cardiologist was misread by the pharmacist as 20 mg Plendil, an antihypertensive drug (Sokol & Hettige, 2006). To conclude, poor handwriting undoubtedly contributes to another inconvenient truth: the high incidence of medical errors as well as effect the health care team provider