Medical Documentation

The Lindsey Clancy trial has brought medical documentation into focus. Observing the differences between doctors and nurses on the stand highlights the current state of the healthcare system.

Though my background is in nursing rather than medical school, the fundamentals of medical documentation remain unchanged. Charting must be clear, concise, complete, confidential, chronological, and consistent.

Importantly, if it's not charted, it didn't happen.

Nurses are trained to document their shifts with patients comprehensively. Accurate and timely documentation is crucial. For instance, when a critical lab value arises and a doctor is informed, the date and time of notification must be recorded. It's essential to document any observed changes and whether a doctor was notified, including the date and time. Administration often pushes for "real-time" charting, meaning documentation while with the patient. Many nurses strive to achieve this, but time constraints make it challenging. Nurses already have limited time with patients, and hospitals' demands for documentation during patient interactions can further distance nurses from their patients. ICU nurse Meghan Collins, who testified in the Lindsey Clancy trial, exemplified effective nursing documentation, confidently presenting her records to illustrate the care provided to Lindsey Clancy. Meghan was certain of her documentation, knowing it accurately depicted her care.

Interestingly, when I review doctors' notes for information, I often find that content has been copied and pasted from previous days, sometimes repeated over several days without updates reflecting the patient's current condition. This practice undermines accurate charting and fails to document the patient's care progression during their hospital stay. Such notes merely fulfill a requirement for the doctor. Unfortunately, doctors are also overburdened with too many patients. I've heard a doctor remark, “this isn’t patient care.” She was right, overwhelmed by administrative expectations. She and her colleagues couldn't provide the care they were trained for or aspired to deliver, merely managing to get by. This situation leads to notes lacking updated information, as doctors focus on meeting administrative demands.

The system's flaws do not excuse doctors. Nurses operate within the same flawed system and still manage to document accurately and promptly. If nurses can't complete charting within their shift, they stay late to ensure the next shift and the healthcare team have access to their notes, which is vital for patient care continuity. Often, doctors' notes are missing or delayed, hindering other doctors and nurses who rely on them to understand the patient's current status. This issue frequently occurs with specialty and surgical team consults.

To understand how documentation functions in healthcare, compare the testimonies of Meghan Collins, RN, and Dr. Jennifer Tufts. Their contrasting approaches underscore the importance of clear, concise, complete, confidential, consistent, and chronological documentation.

Resources

Gutheil TG. Fundamentals of medical record documentation. Psychiatry (Edgmont). 2004 Nov;1(3):26-8. PMID: 21191523; PMCID: PMC3010959.