Everyone in the nursing career field knows that nursing documentation is often the bane of a nurse’s workload. In many cases, nurses seem to spend more time documenting patient care than performing patient care. This is the point of this article on the status of nursing chart writing from the U.K.

This article says that nurses charting are wasting their time on charting when they could be taking care of their patients. I have to disagree with this point. Charting takes care of patients, too. It’s not as hands-on or glamorous as inserting a naso-gastric tube or assisting in surgery, but without it, patients would surely die.

Am I just being sensationalist? I don’t think so.

Let’s look at what proper nursing assessment documentation does for patient care. By carefully documenting what is observed and assessed, the nurse provides valuable trending information for the other members of the patient’s care team from the nurse’s aides all the way up to the patient’s physician.

When the nurse charts his interventions for the patient and evaluates the effects of those interventions, he creates a trending record that gives a very clear picture of the scope of the plan of care for that patient. The article from the U.K. above infers that someone else can help out with the nurse documentation duties. Should someone other than the nurse document that nurse’s actions?

No, because that would be a medication or patient safety error waiting to happen. With the Joint Commission focusing on patient safety and medication errors, having someone else document interventions, progress notes, and even medication adminstration is a recipe for disaster. I’m a firm believer of the credo that the buck stops here.

If I do something, I’m going to make sure it is documented — by ME!