Are You Confident in Your Documentation Skills?

Knowing the importance of accurate, complete, functional, legally-defensible documentation is easy. But learning the documentation skills to accomplish such things is hard.

I’d venture to say that the term “documentation” probably means different things to different people. And I’ll concede that the skills needed to do such “documenting” in one clinical setting aren’t exactly the same as the skills needed to correctly document in another clinical setting. Nevertheless, one must master certain basic principles regardless of the clinical setting.

As you try to wrestle with this, here are some areas where you might want to reflect on your documentation skills.

Is it accurate?

Using the correct terminology is perhaps the most basic skill for professional documentation. Yet, many “professionals” are grossly inadequate in their documentation, and don’t even know it.

Here’s a term that everyone understands, but some use inaccurately. A feed is something like hay that we give to horses or cows. A feeding is what a baby has.

What, exactly, did you do? Did you offer a supplementary feeding, or a complementary feeding? Those are very different.

Here’s one that is incredibly imprecise. A “rash.” There are multiple different types of rashes, and frankly, most of us don’t know, and don’t need to know, which is which, unless we have a state-issued license to diagnose ailments.

Rather than use the term “rash,” simply describe what you see.

Where is it located? What color is it? Is it raised, or beneath the skin’s surface? How large is it? Is it oozing? Is it inflamed? Use as many descriptors as you can.

Recently, I saw that someone had documented that a baby had a “rash.” But what I read in the record didn’t match what I saw when I saw the baby.

The baby had petechiae. That’s not a “rash.” I wouldn’t expect the IBCLC® to recognize petechiae. But the person who used the wrong word set me up for something entirely different than what I saw. Not good.

Here’s another possible weakness in your documentation skills: Using a wrong, unacceptable, or unapproved abbreviation. I’ve seen it probably hundreds of times.    

The first rule is, use only the abbreviations that are on your facility’s list of approved abbreviations.

And while I’m on that bandwagon, let me tell you that every medical and nursing school in the country teaches “BM” from day one. In every hospital I’ve ever worked in, “BM” is on the approved abbreviation list to mean bowel movement. It most certainly does not mean “breast milk.”

Using accurate terminology is fundamental to good documentation skills. Before you write in the record, ask yourself: Am I using the right words and the right abbreviations? 

Is it factual?

So often, we tend to shoot from the hip. For example, writing that someone is “uncooperative” or “stubborn” just doesn’t work.  Any words that are subjective in nature should never be used to describe the client’s or family’s behavior.

When my mother was in a rehab unit, one highly educated “professional” documented in her medical record, “Patient’s daughter verbally abusive.” Wow!

First, that’s a very subjective conclusion. (In truth, I had firmly reminded her that my mother had not agreed to the proposed treatment.)

Second, from a legal standpoint, “It is difficult to define [verbal abuse] and may take many forms.”

Instead, always write objective information. Use quotes to document what the speaker said. Similarly, describe what the individual did without any judgmental descriptors.

Here’s another example: What do you mean when you say, “parents didn’t understand instructions”? How do you know they didn’t understand instructions? Be specific.

Is it complete?

Having good documentation skills means keeping a complete and clear record of what occurred.

Do you worry that you’re leaving yourself open for interpretation that would not reflect well on you? Might it make you seem negligent or something?

Similarly, sloppy or illegible handwriting is another problem. I know, I know, we feel pressured and we get in a rush. Been there, felt that ― more times than I can remember.

But if someone can’t read what you wrote, that’s pretty much akin to being incomplete.

I’m not sure if this counts as a “completion” problem, but it’s a problem because it’s unclear. Do not obliterate what you wrote. The reader should be able to see the original entry. That means, draw one line through what was written, and write “error.”  And yes, some people, especially in private practice, still use paper records rather than electronic records.  

Failure to time, date, and sign an entry certainly makes your documentation incomplete. On occasion, I’ve had to return to the hospital after my shift because I had forgotten to sign something. This is one of the most commonly encountered issues in documentation.

As you reflect on your documentation skills, do you think you write too little (or too much)? Can other people understand what you’re trying to communicate in your documentation?

Is it timely?

Documenting hours or days or even weeks after the interaction or appointment is an issue. (Yes, I just saw this a few months ago. I cringed!) Document immediately after the treatment or the encounter, while the it’s fresh in your mind, or still occurring.

Is it organized?

I don’t know how to describe what constitutes “organized.” I just know that I’ve read hundreds of medical or healthcare records in my day, and sometimes the “flow” makes it impossible for the reader to figure out what happened in the clinical situation.

Watch yourself. One of the reasons professionals document information is to communicate with others who are providing care. If you have written something that makes no sense, well, it’s a deterrent to communication.

Is it compliant with laws and facility standards?

There are few that jump right out at me here.

If you’ve followed me for very long, you know that I’m big on roles, responsibilities, and scope of practice. Your documentation skills should reflect your roles, responsibilities, and scope of practice.

First, ask yourself questions such as, “What am I legally authorized to do?” and “What am I not legally authorized to do?”

I remember the first time I saw in the hospital record that the RN-IBCLC had documented in the record that she had “prescribed metoclopramide.” She was not an advanced practice nurse with prescriptive privileges. Hence, she just put herself at great risk. She documented that she did something she wasn’t legally authorized to do!  Remember that your documentation should be a record of what you’ve seen and what you’ve done. So while she was correct in documenting what she’d done, she shouldn’t have done it in the first place.

What about system-level and external issues?

Do you have trouble completing forms from outside sources? If so, ask for help so that you can clearly communicate with others outside of your own facility.

System issues:

System-level documentation is a whole other kettle of fish. Yet, if you’re in any type of leadership position, you’ll find yourself writing policies, procedures, and more.

It may sound a little crazy, but I actually enjoy writing documents that help to bring about system-level communication and system-level compliance. Most of my clinical experience has been in hospitals, and I admit that a lot of what’s written is never understood, much less implemented. But it doesn’t need to be that way. Be clear and concise, yet thorough if you’re taking the lead on drafting these documents. 

Do you think you don’t need policies and procedures if you are running your own practice? Oh, my friend, think again! You definitely need those, and many more!

You’ll also need to have standards for non-clinical things like refunds, payment processing, and job descriptions. Here’s another one: For many years, we’ve had a corporate policy saying that we do not accept any funding from companies that violate the World Health Organization’s International Code of Marketing of Breastmilk Substitutes. The list goes on and on.

Nowadays, with the advent of electronic medical records, issues of accuracy, completion, timeliness, organization or compliance are minimized because the writer merely needs to check a box. But in some settings (e.g., private practice) or some countries around the world, such a streamlined system may not be what’s at hand. 

Documentation skills are a huge part of healthcare. You can’t escape it. So, make sure that you’ve got the skills you need to do it right, or at least do it better today than you did yesterday.

Are you confident in your documentation skills? In what areas do you struggle? Share your experience in the comments!