Not
Documented
Not
Done

January 11, 2018 -- "If it wasn't documented, it wasn't done." We nurses have had this drummed into us. Seems logical, right? Our coworkers need to know what care has been delivered (or not delivered) and the lawyers do, too. Or do they?

It's counterproductive! We waste so much time in front of the computer. For example, why document hand-washing?

There are only three reasons to document in healthcare, and CYA isn't one of them. The three reasons are:

  • It is meaningful for patient care.
  • It is necessary for regulatory requirements.
  • It is needed for billing.

As EHRs mature and begin to support -- not impede -- nursing workflow, dogmas such as this one are at last being abandoned.

Cartoon by Charles Keller (Dan's Dad)

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