The shunned nursing note

Quality documentation is a integral part of our job. The care that we provide is always judged by the kind of documentation that we do. 

If a thing is not documented, it is not done. 

At the same time, there is something very unusual here, a big disconnect between the physicians and the nurses. I have always witnessed nurses checking out and reading a physician's note but a physician reading a nursing chart is a rare sight. Most of you would agree that physicians do not pay much attention to the nursing notes unless they are in the soup. And if you ask me why do physicians do this, I would say that this can be a multitude of reasons for doing that like a physician's ego, lack of trust, lack of a rapport or they just don't care about what nurses document. 

Everything goes smooth until and unless there is a mishap and a lawsuit. And in the court of law the documentation done by the physicians as well as the nurses is frequently scrutinised to review the case and understand the timelines. Things can really go out of the track  because of a mismatch between our notes. So, the importance of nursing notes cannot be underestimated. 

As compared to a doctor's documentation, nursing documentation is much more comprehensive in terms of the vital signs monitoring, communication and ongoing patient care. In my opinion, a nursing note is far more detailed, legible and honest. Next time, have a glance through their note and you will be surprised to find that how thorough they can get. You will find every minute aspect of patient care documented like assessment, what the patient exactly said, monitoring, counselling, teaching, medications, verbal and written orders, compliance, evaluation , plan and communication about all this with the physician. You might also find your name documented in their note! 

So, don't you think we should pay a bit more attention towards all their hard work? If not for all the patients, at least for those who are getting discharged from the ED  and for the ones who are critically ill.

When evaluating a patient in the ED, we need to remember that the documentation actually starts from the field followed by triage notes, nursing assessment and then the physician notes. Our responsibility then is to do our own history and physical rather than duplicating the same notes again. It is also crucial to be aware of the timelines and make sure that there are no discrepancies between the physician's and the nursing note. If there is a discrepancy, then mention that in your chart with reference to the nursing note to make sure the message is conveyed clearly. 

A typical nursing note: (it can get much more detailed)

14/03/2015  0900hrs Patient received on Bed No. 4. He is alert and oriented to time, place and person. Complaining of headache. No H/O Allergies. VS: PR 98/min  BP 110/74  RR 14/min SpO2 99% RA, Afebrile. Inj.  Acetaminophen 1gm IV given over 30 minutes through left ante cubital vein. Monitored continuously for medication effects and adverse effects. No other concerns verbalised at this point. Informed to the resident physician (Dr. XYZ) on shift. 

14/03/2015 1130hrs Patient now complains of severe pulsating type of headache and nausea. Says "This is the worst possible headache he has experienced so far". Looks distressed. VS: PR 108/min BP 150/88 RR 17/min SpO2 98% RA Temp -100F. Informed to the on duty physician (Dr. XYZ) STAT. Inj. Ondansetron 8mg IV and Inj. Fentanyl 50mcg IV administered. Patient seen by the physician and is scheduled to undergo a Non-Contrast Head CT scan. To be shifted to CT room on call.

The key point that I want to highlight here is that doctors and nurses need to start communicating well with each other. For physicians, it is good to have a sense and understanding about nursing documentation. 

Take Home:

• As physicians, make a habit of going through the notes of other healthcare providers (nurses/ paramedics) prior to discharging a patient and be on the same page with them.
• Good communication will improve patient care and prevent litigation.
• Documentation is not just for our self defence but also to foster patient care. 

For further reading:

http://thenursepath.com/2013/10/09/documentation-vs-communication/

https://crnns.ca/wp-content/uploads/2015/02/DocumentationGuidelines.pdf