Why Double Documenting Is A Bad Habit
Imagine being called into your manager's office. They sit you down and tell you that there is a problem.
The patient you took care of two weeks ago, who aspirated, has filed a complaint with the hospital that you didn't practice under the "standard of care." The complaint says that if he would have been placed in a higher bed position, he wouldn't have aspirated.
But you always keep patients like him with this condition at 45° or higher. Always.
It just so happens that during an audit of your charting, you happened to put 45° as a head of bed in your nursing note, but selected 15° in another area of the record for the same time. Because you noted two very different things at the same time, it's now a problem. You've violated one of the golden rules of documentation, which is to never double document!
Double Documentation - What is it?
Double documentation is the practice of denoting care (or inputting data) in two locations in a medical record. It's a totally unnecessary practice, and can potentially cause problems for the nurse, for the patient, and for the hospitalization.
Why It's A Problem
When we look at medical records as a whole, they serve several different purposes.
First, they serve as a record of care provided to patients.
Next, they serve as an ability for multidisciplinary teams to communicate the plans, orders, and outcomes of patient care.
They also function as ability for scheduling, continued care, and billing. Depending on the complexity of the system, they can also have many other different functions.
One of the major problems that exists is that a key function of the electronic record is that it is focused on the central idea of communication, especially between disciplines.
This becomes extremely problematic when nurses document in two places for the same care. It doesn't improve communication - it clouds it!
Why Does Double Documentation Continue?
There are three central reasons why double documentation continues, as a whole.
The Perpetuation of Poor Tribal Knowledge
Basically, this is just my way of saying "we've always done it this way." As nurses, we focus so heavily on evidence-based practice, that we nearly live and die by it. Just because nurses in a particular unit, or particular organization have always "done it that way," doesn't mean that it's the right way. Remember, we have to uphold the standards of care, and if we are clouding our ability to communicate, this deviates from the plan.
The challenges that many nursing leaders face is that they are responsible for higher priority items in managing staff, patients, and units than they are with the concept of documentation. But the fact is, because this is a lower priority item, many actions on behalf of management, leadership, and even veteran nurses are reactionary. Instead of making change as a part of onboarding, they serve as a reactionary representation during RCAs (root cause analyses) to identify causes.
Lack of Documentation Standards
This is probably the most common cause of double documentation. There are so many different standards of care, depending on the accrediting body, that there is no general "standard" as to what should be documented. Because of this, it creates a lot of ambiguity. Nurse managers don't know what the standard should be, preceptors perpetuate bad habits, onboarding staff cannot train appropriately, and many nursing programs lack a dedicated documentation course. And what it ends up coming down to is we lean hard into those bad habits.
What Can Nurses Do To Avoid Double Documentation?
When you continue to double document (or double chart), what you start to do is create bad habits. These bad habits continue in your own documentation, and you can fall into the "perpetuation of poor tribal knowledge" category. But, by understanding the causes of double documentation, you can begin to make the necessary changes to improving the quality of your charting.
So what steps can you take to avoid them?
Work with your trainers and educators on understanding where things might show up twice in an electronic record.
Utilize your nursing note for everything that can't be documented somewhere else. Use the nursing note to paint a picture of care - don't use it as the default documentation method.
Work with nurse leaders and management to understand the standards of documenting care for your organization or unit. By doing this, you can really hone in on the important documentation items and make it an extension of your care.
Lastly, and most importantly, visit your state board of nursing website and look for your state's "standard of care" when it comes to documentation. You can almost never go wrong!
The goal of this website is to give you the ultimate resources to improving your practice of documentation. Please remember to always practice an abundance of caution and seek out answers regarding the legality of your documentation with your organization or through your state board of nursing.