Documentation

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You are an LPN working in a long-term care facility. You receive a call from an LPN colleague who just finished her shift. She tells you that she forgot to document an assessment and care provided for a resident. She asks you to do it for her. What are your responsibilities in this situation?

 

A: Respectfully refuse to document the care that she has provided. Leave a blank space in the resident’s chart so that she can document when she returns.

That’s not correct. Follow agency policy to correct documentation errors; never modify or delete information that is recorded on the health record. Do not leave blank lines between entries. Do not erase or black out an error and do not squeeze entries between lines. See Applying the Principles to Practice in the Documentation Practice Standard.

B: To ensure continuity of care, take notes about the care she provided. Then document the care provided in the resident’s chart.

That’s not correct. Document only the care you provide; do not allow others to document for you. Do not document care that another health care provider does, except in an emergency, such as a cardiac arrest where the LPN may be the recorder. See Applying the Principles to Practice in the Documentation Practice Standard.

C: The resident’s condition hasn’t changed, so there is no need for either you or your colleague to document the assessment or the care she provided.

That’s not correct. Recognize that, in a court of law, accurate, complete and timely documentation may lead to the conclusion that accurate, complete and timely care was given to the client. The converse is also true. If it is not documented, it is questionable if it was really done. If extensive time has elapsed between making entries, then a late entry must be clearly identified. Record the date and time of the late entry, as well as the date and time that you actually provided the care. See Applying the Principles to Practice in the Documentation Practice Standard.

D: Respectfully refuse to document the care that she has provided. Ask her to make a late entry when she returns.

Correct! LPNs are responsible and accountable for documenting on the health record the care they personally provide to clients. Except in an emergency, LPNs are not responsible to document care given by other health care providers. LPNs correct any documentation error in a timely, honest and transparent manner. LPNs clearly mark any "late entries," recording both the date and time of the late entry and of the actual event. See Principles 1 and 5 respectively in the Documentation Practice Standard

Documentation is any written or electronically generated information about a client that describes the care or service provided to that client. It is an integral part of nursing practice and quality care.

Documentation serves three purposes:

  1. facilitates communication;
  2. promotes safe and appropriate nursing care
  3. meets professional and legal standards.

A practice environment that has the necessary systems, supports and policies in place to enable LPNs to document appropriately, is fundamental to safe client care.

Photo courtesy of the US Army in Korea