I was seconded a little while ago for a couple of weeks to do administrative duties, among which were some chart audits. This is where we pulled old Emergency Department charts and compared them to a check-list of essential criteria for having sound documentation. We looked at whether initial nursing assessments were complete. Were vital signs taken according to policy? Were the orders signed off? Were discharge instructions given? The list was long, and almost each check-off represented a point where a nurse could be called to account for poor practice
For reasons of liability, accountability, and most importantly, patient safety and continuity of care, good charting is a nursing essential. Why? Because the chart is the principal way health care professionals communicate with each other. We all make clinical decisions based on the information found in the chart, and if information is missing or inaccurate, we may jeopardize patient care.
And frankly, in the never-ending Quest for Good Charting, we collectively sucked.* I’m not talking about whether nurses were completing Form 5435-xy-125 documenting the chain of custody of the patient’s lower plate, either. There were some pretty egregious examples. No initial vitals signs charted on some charts. No assessment of peripheral capillary refill on children. No chest assessments on patients with presenting with cough and dypsnea. A patient in hypertensive crisis given an antihypertensive with no follow-up blood pressure documented. I was actually embarrassed for my colleagues — and myself. To be clear, I am not suggesting that the nursing care was ever as poor as these charts might suggest, though the blood pressure chart did give me pause. But it’s also an old maxim that “if it isn’t charted, it isn’t done.”
The missing piece of information which bothered me the most was the lack of charted pain evaluation, and unfortunately in this instance, I could show pain was not being assessed at all. Let me explain. Lay people who have travelled in the land of health care are probably familiar with this question: “On a scale of one to ten, with ten being the worst possible pain, how would you rate your pain?” This question is important, and not only for the obvious reasons of providing effective pain control. In the Canadian Triage Acuity Scale (CTAS) system, the pain scale forms a crucial element of determining a triage score and in turn, priority of care, because the level of pain is correlated to the severity of the patient’s condition.
Alarmingly, many of the charts audited had no triage pain assessment, meaning the triage score was unreliable. Patients presenting with chief complaints of back pain, for example, were routinely triaged as “4,” that is “Less Urgent,” without any pain assessment being done at all. A pain scale of 8/10 would bump these patients to CTAS 2 (Emergent), which of course determines a whole other priority for care. I understand why the chief complaint of “back pain” did not receive adequate pain assessment: patients presenting with such are often unfairly labelled as drug seeking. Trouble is, I can think of many problems which present as back pain, that are unrelated to either mechanical injury — which can be serious enough — or drug seeking behaviour, ranging from renal calculi to dissecting aortic aneurysm.
The point is, poor charting on the part of nurses can lead to bad patient outcomes. Part of the problem is that nurses are overwhelmed by the documentation they are required to managed. Charts are full of administrative trivia unrelated to the actual provision of health care, yet nurses are expected to treat this flood of paper as being as important as documenting the care itself. (I know this situation is far better in Canada than the United States, where charts take on encyclopedic length before ever leaving the ED.) When nurses face ever-increasing workloads, higher patient acuities and volumes, and the consequential time constraint, the choice is often literally between actually saving lives and writing it down in the chart in an adequate manner. Guess which wins.
But in the end is the plea of “I don’t have the time for good charting” really a good excuse, especially when licences are potentially on the line? This is to say, nurse managers must be pro-active in insisting their staff are given the space to chart properly, and front-line nurses must be equally clear good charting is not optional. Yet, to be honest, in reading though the charts during the audit, I sensed that a lot of nursing care was routinized, that there wasn’t much critical thinking going on between the lines — what wasn’t charted was, in fact, never done. For good patient care, this is the greatest danger of all.
*Note to any educators: an hour or two of chart auditing is guaranteed to cure the most recalcitrant nurse of poor charting. I think of myself as a reasonably conscientious charter, having worked in the U.S., but even for me, it was a real kick in the pants.