DOCUMENTATION

Clinicians often ask what constitutes sufficient documentation; the answer varies with each call. Emergent symptoms will require minimal data, whereas vague abdominal pain may require many pieces of data. Pertinent negatives are documented to demonstrate that urgent symptoms were ruled out.

Documentation by Exception and by Inclusion

When it comes to documentation at the bedside, some maintain, “If you don’t document it, it wasn’t done.” What constitutes safe, effective, and appropriate documentation is an area of considerable controversy, and there are at least two schools of thought on the issue: documentation by exception and documentation by inclusion. Each has certain advantages and risks.

Documentation by exception, the method typically used by physicians, means that questions are asked, but negative responses need not be documented. Thus, with chest pain, physicians would not document “denies sweating, shortness of breath.” This approach reduces time-consuming documentation to a minimum. The physician is not made to look negligent for anything not documented. The risks are that no one can prove that standardized questions were indeed asked or what the response was, unless the call was audiotaped.

In contrast, documentation by inclusion, typically used by nurses, requires that the nurse chart normal (pertinent) negatives as well as abnormal findings (pertinent positives). Pertinent negatives are findings that are normal and significant (e.g., “denies black or bloody stools”). If charting by inclusion, both pertinent negatives and pertinent positives are always included. If they are not, the clinician may appear not to have asked “rule-out” questions and may appear negligent. It is more burdensome and time-consuming to document by inclusion, but it presents a more comprehensive picture of what happened during the call.

In telephone triage, the issue of documenting by inclusion or exclusion is best addressed by consulting nursing standards and in-house legal counsel and developing written policies.

Because clinicians may fail to adhere to polices or have very strong positions on the appropriateness (or lack thereof) of the documentation method in use or proposed, ensuring compliance must include:

• Education, at time of hire, annually as part of competency evaluation, and when indicated by evidence of slipping compliance
• Management support
• Working individually and objectively with resistant staff to gain cooperation

Documentation Formats

Paper documentation forms and electronic medical records (EMRs) support the nursing process, maintain standards for continuity, provide informed consent, enhance quality assurance, and reduce human error. Forms can also augment nurses’ memories and offer proof of advice given, thereby increasing defensibility in the event of litigation. In combination, guidelines and electronic medical records have a role in documentation as well by expediting the collection and recording of information.

Most clinicians start out transcribing information volunteered by the patient as they “tell their story,” since the patient’s first utterances are often the most accurate and important. They then follow up with SCHOLAR questions. Likewise, RAMP questions may easily be built into the EMR. It is critical to document the patient’s age, emotional state, any threats of litigation, presence of a language barrier, and any extenuating circumstances (recent death in the family, loss of job, recent car accident). Documentation forms and EMRs incorporate blank spaces as well as checkboxes, and most clinicians prefer to have both formats.

Audiotaping of calls has certain advantages. Wording and voice intonation can be reproduced precisely. However, unless transcriptions are immediately accessible, unlike written records, audiotapes cannot immediately relay information to other providers, which might compromise continuity of care.

Documentation Essentials

Documentation must be concise but complete, including accurate, timely observations in the patient’s own words, always using approved abbreviations and terminology.

1. Quantify where possible; avoid vague expressions. Use measurable terms (e.g., pads per hour, diapers per hour, numbers of diarrhea or vomiting episodes).
2. Use time frames (e.g., 8, 16, 24, 48 hours) when assessing symptom duration for a more comprehensive baseline picture.
3. Form a provisional, working diagnosis or impression.
4. Document advice per guideline name or number.
5. Document guideline deviations/overrides/modifications.

Detailed, concrete documentation demonstrates the clinician’s efforts and supports the disposition and advice. Effective documentation is streamlined by using explicit terms and avoiding ambiguity. The more concrete, the better. Specific adjectives (qualitative) are used to describe symptoms and the patient’s emotional tone.

EFFECTIVE VS. INEFFECTIVE CHARTING

Effective	Ineffective
Concise: “Abdominal pain x 3 days. Denies nausea/vomiting/diarrhea.”	Long-winded: “Patient states she has had severe abdominal pain for 3 days. She denies any nausea, vomiting or diarrhea.”
Detailed: “8 loose, watery, green stools x 16 hours.”	Vague: “Diarrhea.”
Detailed: “On penicillin 500 mg four times/day for 48 hours.”	Vague: “Taking antibiotics.”
Specific: “Worst headache I’ve ever had, splitting, throbbing.”	General: “Severe headache.”
Concrete: “Voice is high pitched, speech rapid. Called three times in 2 hours.”	Subjective: “Seems anxious.”

SAMPLE TELEPHONE TRIAGE DOCUMENTATION FORM

(Wheeler, 2013. Used with permission.)
Name	[  ] Adult [  ] Pediatric
Date Time          AM  PM	Age DOB Sex   M  F
Phone	Caller Relation to Patient
Hx Prematurity?   Y  N	Weight Temp (Oral AX Rect) BP
Immunizations up-to-date?   Y  N  (N=Needs appointment)
Chief Complaint
Key symptom history (use SCHOLAR, ADL, A DEMERIT, SEPSIS checklists)
Home care administered?   Y  N
Last menstrual period Pregnant?   Y  N Breastfeeding?   Y  N
Allergies?   Y  N
Chronic illness?
Emotional state?
Medications?   Y  N
Recent injury?   Y  N
Recent illness?   Y  N
Recent ingestion?   Y  N
Impression
Guideline title or number
Guideline modifications
Advised to be seen within        Mins       Hrs	Appointment Date Time
Mode of transport
Precautions stated?   Y  N	Patient agreement to plan?   Y  N
RN signature/title
Time call ended                 AM  PM