Documentation is a very critical area in healthcare. All health practitioners need to document what they have done to patients. In hospitals, patient files are used for documentation of the care given to the specific patient. There are several types of documentation forms found in hospitals. They include the nursing cardex, fluid charts, input and output charts, vital signs monitoring charts, radiology charts among others. All these forms indicate a certain type of event that occurred in the care of a particular patient (Paans & Müller‐Staub, 2015). Even doctors have portions in the patients’ file where they need to comment on what they have done and what their orders are.
The culture of documentation has existed for a long time. It shows accountability and responsibility. A signature usually accompanies the notes that any practitioner puts down. The modernization or documentation still maintains the same principles. The practitioner who does the job should be the one to document. If it was not documented, it has not been done. Documentation provides evidence of what the patient has been through and whom they have interacted with (Usher et al., 2016). It is part of the evidence-based practice that is upheld in all health care institutions worldwide.
When health care workers fail to document, it creates gaps in the continuity of care. Instances of missing information have led to mismanagement of patients by different practitioners. When a nurse fails to document a procedure that has been done, there is a risk of repeating the same procedure by another nurse (Paans & Müller‐Staub, 2015). When a doctor does not document instructions he or she has given, it is impossible to know what needs to be done when a shift changeover occurs. When nutritionists and physiotherapists do not record what they have done, it may seem as if they are not doing their work.
Poor documentation also has effects. Poor documentation means that whatever is written cannot be understood, has been wrongly written or has been written in the wrong area. All these components of poor documentation make it hard to know what the writer intended. Making assumptions based on poor documentation can have catastrophic consequences for the patients in the hospital (Palojoki et al., 2017). It also confuses health care workers causing some impairment in their ability to deliver quality care.
Failure to document and poor documentation has had a significant impact on patient outcomes. Research has shown that they are the reason for medical errors such as missing medication, repeating medication, missing a procedure among many others (Palojoki et al., 2017). Such kinds of errors cause patient dissatisfaction of care. It also portrays health workers as poor and non-professional in their practice.
Everyone working in the health care sector especially those in health care institutions should know how to document the various documents available for patient care. Good documentation ensures that a patient has a good hospital stay, receives the care he/she requires and recovers on time to go back home. Health workers should take documentation seriously and practice it daily in their patient interactions (Usher et al., 2016). This way, there will be less mismanagement and better service delivery in health care institutions.
Paans, W., & Müller‐Staub, M. (2015). Patients’ care needs: Documentation analysis in general hospitals. International journal of nursing knowledge, 26(4), 178-186.
Palojoki, S., Mäkelä, M., Lehtonen, L., & Saranto, K. (2017). An analysis of electronic health record–related patient safety incidents. Health informatics journal, 23(2), 134-145.
Usher, M. G., Fanning, C., Wu, D., Muglia, C., Balonze, K., Kim, D., … & Herrigel, D. (2016). Information handoff and outcomes of critically ill patients transferred between hospitals. Journal of critical care, 36, 240-245.