If it’s not documented, it’s not done. But what if it is documented and it’s not done? (Page 40)

By Jackie Russell, RN, JD

MNA Nursing, Practice, and Regulatory Affairs Specialist

If it’s not documented, it’s not done. But what if it is documented and it’s not done?

Healthcare facilities throughout Minnesota are short staffed. Patient acuities are high, and lean management demands nurses spend less time with patients, which is distressing to nurses. Nurses have a duty to provide nursing care within their scope of practice and to practice safely. Priorities shift quickly on a short-staffed unit. To provide optimal nursing care on a short-staffed unit– from beginning to end of shift–leaves little time for timely documentation. More and more nurses feel staying after their shift to get caught up on patient documentation is a necessity, not a choice.

On the flip side, some Electronic Medical Records (EMRs) allow for cut and paste or carry forward documentation. Nurses question whether documenting ahead when an assessment pattern has been within normal limits (for example, a cardiac patient with normal GI assessments over several days) is ever okay. The answer is no. Whether waiting to document until the end of shift or documenting ahead to stay on top of it, the documentation is not “timely.”

The documentation is not contemporaneous with your nursing assessment, patient care, and patient outcomes. In other words, if it’s not documented when it happened, maybe it didn’t happen that way. Untimely documentation is considered false, untrue, misleading, and deceitful. Untimely documentation may also be considered fraud. False, misleading, and deceitful documentation may result in grave safety issues for the patient because the healthcare team depends on accurate and timely documentation to make patient care decisions. If a medication, assessment, procedure, etc., is not timely then other care providers do not have an accurate account of a patient’s condition which may lead to poor outcomes, including death. In the event of a malpractice lawsuit, a plaintiff’s attorney will argue that documentation that is late by hours or days is self-serving. Hind sight is 20/20.

Although you may not have intent to falsify, deceive, or mislead, the more time that passes between the assessment or procedure, the more likely suspicion can be drawn of bad intent. Especially if a patient suffers an injury.

As for documenting ahead, you may have all the confidence in the world nothing will occur that would change that account, that is not always the case. Never doubt that any patient status can change in the blink of an eye– any patient status.

Your nursing license is a privilege provided to you by the State of Minnesota for the purpose of providing safe patient care. It is imperative that as a nurse licensee, you never falsify nursing documentation, or any document, in relation to your nursing practice.

Documentation is the first thing attorney’s and hospital superiors will scrutinize in the event of a medical or nursing liability claim. The ramifications of falsifying records may be a nursing liability, encumbered license, or loss of your license. Another consequence is, your veracity as a nurse will be severely compromised.

Documentation that is a complete, accurate, timely account of a patient’s condition or status is your best defense against litigation.